This page is for current student-athletes at Southern Illinois University. If you are not currently on a roster please see the link for Prospective Student-Athletes.
Please complete the following forms prior to the start of each academic year or if any of your personal information changes:
Interim Medical History: If you have had any injuries or illnesses in the last that have limited your participation in any sport please indicate those injuries/illnesses. If you sought medical care for these conditions away from SIU please send us your medical records and any X-rays, MRIs, lab results, or other information regarding the condition that you and/or your doctors have.
HIPPA/Buckley Form: This form allows the sports medicine staff to communicate with coaches, administrators, and other personnel on issues that would affect participation in intercollegiate athletics. The Authorization/Consent for Disclosure of Protected Health Information should be completed, signed, and dated.
Student Health Center Release of Information Form: This form allows the medical staff at the SIU Student Health Center to communicate with your athletic trainers on issues that would affect participation in intercollegiate athletics.
Fill in Name, phone, ID # (this is your DawgTag), and date of birth. In the Dates of Records to be Released put the date of your signature in the "from" section. For example, if you are filling out the form on July 27, 2010, your blanks would read, "From 07/27/10 To: 08/10/11". Sign and date in the appropriate space.
Student-Athlete Family Insurance Information and Record Release Form: This form regards any health/medical insurance that you and/or your parents may carry on you while you are at school in Carbondale. Even if you don't have any medical insurance please fill out the top section of the form with you and your parents/guardians information. This form must be filled out annually, or when there are any changes to health insurance coverage through the family. Even if there are no changes to insurance coverage since the previous year's form was completed a new form should be completed and signed each year.