PITTSBURGH STEELERS
2008 Men’s Fantasy Football Camp
presented by Rolling Rock
PARTICIPATION AGREEMENT
I, the undersigned, in consideration for the opportunity to tryout for the Men’s Fantasy Football Camp, agree to hold harmless for medical expenses and/or other compensation the Pittsburgh Steelers and their officers, directors, shareholders, and employees, in the event that I am injured while participating in the camp or while I am on the St. Vincent campus.
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Athlete SignatureDate
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Witness SignatureDate
MEDICAL HISTORY
NAMEBIRTHDATEDATE
PREVIOUS NFL TEAMSSOCIAL SECURITY #
DO YOU NOW HAVE OR HAVE YOU EVER HAD:
YES DATEYES DATE
Measles Rheumatic Fever
German Measles Diphtheria
Chicken Pox Heart Disease/Murmur
Whooping Cough Pneumonia
Scarlet Fever Influenza
Bone Disease Pleurisy
Neuritis/Neuralgia Arthritis
Anemia Rheumatism
Jaundice Polio or Meningitis
Epilepsy Gout
Migraine Headaches Venereal Disease
Mononucleosis Tuberculosis
Malaria Diabetes
Kidney Disease Cancer
Appendicitis High/Low Blood Pressure
Varicose Veins Hay Fever/Asthma
Liver Disease Boils
Gall Bladder Hepatitis
Tetnus Shot Ulcer
Colitis Hemorrhoids
Pneumothorax Heat Exhaustion/Stroke
Concussion Other
HAVE YOU EVER HAD ANY OF THE FOLLOWING SYMPTOMS?
YESYESYES
Fainting SpellsHearing LossShortness of BreathUnconsciousness Depression/Anxiety Fluttering Heart
ParalysisHallucinationsFatigue Easily
ConvulsionsEnlarged GlandsConstipation
DizzinessChest PainDiarrhea
FrequentIndigestionExtreme Bleeding
HeadachesCoughing BloodDifficulty with Urination
Frequent ColdsFrequent CoughsVision Loss
Frequent Sore ThroatsBack Trouble
ARE YOU ALLERGIC TO ANY OF THE FOLLOWING:
YESYESYES
AspirinOther AntibioticsOther Drugs
CodeineAny FoodsBee/Insect Sting
MorphineAdhesive TapeOther Allergies
PenicillinCosmetics
ARE YOU CURRENTLY TAKING ANY MEDICATION? IF SO WHAT?
DO YOU TAKE ANY MEDICATION OTHER THAN OCCASIONALLY? IF SO WHAT?
SURGERY/HOSPITALIZATION. GIVE DETAILS.
Condition or InjuryDATE
Town/Hospital
Condition or InjuryDATE
Town/Hospital
Condition or InjuryDATE
Town/Hospital
HAVE YOU EVER:
YESYES
Had an Artificial Eye Worn False Teeth/Bridges
Worn a Hearing Aid Been advised to have surgery
Worn Glasses Been denied employment due
Worn Contacts to a medical condition
Been told you had Sickle Cell
FAMILY HISTORY
Has anyone in your family ever died suddenly?
If yes, explain.
Have you had any other medical conditions not listed?
Explain any yes answer.
I certify that I have made full and complete written disclosure of all past and present injuries.
DATESIGNATURE
GENERAL INFORMATION
EMERGENCY INFORMATION
ALLERGIES: ______
MEDICAL ALERTS: ______
EMERGENCY CONTACT: ______RELATIONSHIP: ______
EMERGENCY CONTACT PHONE #: ______
2007 Tryout Physical Form
Updated 10/5/18