NYACK COLLEGE WARRIORS

PHYSICAL EXAMINATION REQUIRED FOR TRY-OUTS

1 South Blvd, Nyack, NY 10960
SPORTS MEDICINE DEPARTMENT (845) 675-4780  Fax (845) 675-4771

Since Nyack College is a NCAA Division II institution, in order to try-out for an intercollegiate athletic team here at Nyack
College, you must present a medical examination signed by a doctor within 6-months prior to the date of your try-out or a
copy of your physical from the start of this school year from your current institution. Print this form and take it to your
doctor and bring it with you to your try-out. Also, the NCAA requires you to show documentation of being Sickle Cell Trait
Tested. Please attach a copy of the documentation to this form (just a doctor’s note will not be accepted).
NAME- DATE OF SOCIAL
Taylor Young BIRTH- 02/02/2005 SECURITY#- SIN (Canda) 662376201
ADDRESS- HOME PHONE-
14105 valley view drive Edmonton Alberta T5R5V1 N/A
EMERGENCY RELATION CELL
CONTACT- Steven Young TO ATHLETE- Father PHONE- 780-863-2794
HEIGHT- 5’10 WEIGHT- 160 EYES- Blue BLOOD HEART
PRESSURE- 110/70 mmHg RATE- 70 bpm
ALLERGIES- none MEDICATION- none

GENERAL EXAM NORMAL ABNORMAL FINDINGS

HEAD/SCALP Nil
NECK Nil
EYES/EARS Nil
NOSE/MOUTH/THROAT Nil
HEART Nil
LUNGS Nil
ABDOMEN Nil
SKIN Nil
GENITALIA Nil
HERNIA Nil
ORTHOPEDIC EXAM NORMAL ABNORMAL FINDINGS
NECK Nil
SHOULDER Nil
ARM Nil
ELBOW Nil
FOREARM Nil
WRIST Nil
HANDS/FINGERS Nil
BACK/SCOLIOSIS Nil
HIP Nil
LEG Nil
KNEES Nil
CALF Nil
ANKLES Nil
FEET/TOES Nil
ARCH Nil
FUNCTIONAL EXAM NORMAL ABNORMAL FINDINGS
SPINE ROM Nil
JUMP Nil
HOP Nil
SQUAT Nil
DUCK WALK Nil
COMMENTS- NIL

I have examined the above athlete and have determined them medically healthy and capable to
try-out for an intercollegiate team at Nyack College.
PHYSICIAN SIGNATURE- PLEASE PRINT PHYSICIAN NAME- DATE-
ADDRESS- PHONE
11996 109A Avenue, Edmonton, Alberta NUMBER- 780-484-0514