NATIONAL ASSOCIATION OF INTERCOLLEGIATE ATHLETICS
DIVISION II WOMEN’S BASKETBALL NATIONAL CHAMPIONSHIP
Visiting Team Medical Questionnaire
Please complete and forward this form to the Host Medical Coordinator/Athletic Trainer prior to the event. Contact information is included below. All information is completely confidential and is strictly used to assist the medical staff in preparing for your arrival.
Name of institution: / Head Coach:Name of Certified Athletic Trainer:
Will you be traveling with the team? / Yes No
Name of Student Athletic Trainer:
Will student trainer be traveling with the team? / Yes No
Name of Team Physician:
Will the physician be traveling with the team? / Yes No
*Do you want the Host Physician to attend to your injured athletes? Yes No
*Do you want the Host Athletic Trainer to attend to your injured athlete? Yes No
*In the event you have a team physician and/or certified athletic trainer with your student-athletes, the host physician and/or certified trainer will assist only if requested to do so.
In the event that a Certified Athletic Trainer is not traveling with your team, please list any necessary treatments for your student-athletes to be performed by the Host Athletic Trainer:
In the event that a Certified Athletic Trainer is not traveling with your team, please list any special needs or concerns regarding your student-athletes that would be helpful in an emergency situation (i.e., diabetic, epileptic, allergies to medications, medications, etc.):
Name: / Date:Signature: / Phone:
E-mail address: / Fax:
Please return to:
Brian Collette, M.Ed., ATC, LAT
CNOS / CNOS Foundation
575 Sioux Point Road
Dakota Dunes, SD 57049
Fax: (605) 217- 2928