Medical Forms

Dear Student Athlete,

I would like to welcome you to the Herkimer College athletic family. I hope you have a safe and injury free experience. Unfortunately, accidents and injuries do occur in athletics. This sometimes involves bracing, rehabilitation, doctor and emergency room visits. We at Herkimer College, want to ensure that you will receive the best possible care and in a timely fashion. In order to expedite this process some information must be provided prior to your participation.

Below you will find links to forms that you must print and fill out in entirety and to the best of your knowledge. This information is required by both the NJCAA and Herkimer College, prior to your participation in athletics. If these forms are not filled out completely you will not be allowed to try out or participate in Herkimer College athletics. A photocopy (front and back) of your current medical insurance card should be on file prior to your participation. Additionally all athletes are required to purchase a supplemental student accident insurance through the school, for a small fee. The supplemental student accident insurance is a secondary insurance, that helps cover medical costs not covered by your primary insurance in the event of an athletic injury. This is all done to ensure you have a safe and healthy experience here at Herkimer College.

The medical history form should be completed and signed by the student athlete. Use the drop down list of “yes” or “no” for each question and please provide dates and details when specified. If you commute from home, write “commute” for the school address. The release/waiver form should be read and signed by the student athlete. If you are under eighteen, this form should be also signed by a parent or guardian. Both of these forms can be downloaded, edited, and saved to a computer and uploaded to an individual’s athleteconnection account or printed, filled out, and delivered by the student athlete at the initial sport meeting. The physical exam form should be filled out by your physician. The exam should be dated after June 15th, and must clearly state that you may participate in intercollegiate athletics with no limitations. If you are currently under the care of a physician, physical therapist, chiropractor, etc. for an injury or illness, please have that health care provider fill out a referral form. A written statement by them is required prior to your participation. A copy of your immunization records are also needed prior to your participation.

All medical information is strictly confidential and will be used as an aid in providing you the best health care possible while you are a student athlete at Herkimer College. In order to ensure this privacy, your knowledge and written consent will be required prior to release of any personal health information.

Herkimer College uses a website for student athletes to input and upload all the information required to participate in Herkimer College Athletics. The following is instructions on how to set up an account and start the process of adding the information required.

1) The AthleteConnection website address:
2) The account group and account code that together will identify the athlete’s account as belonging to your school or organization. The Herkimer College coaching staff will be able to provide the account group and account code required to connect to Herkimer College.
3) Instructions for creating a student athlete account:
a. Visit this website in your browser:
b. Click the Register link to create a new account, using the account group: 10753 and account code: 5887406 provided.
c. Once your account has been created, you will be taken to your profile page. Your identification # is your social security number. Please complete the information on this page and click the Save Changes button when you’re finished.
d. You can update your profile at any time by logging on to your account at

Everything must be completed and returned to Herkimer College by Monday, August 10.



Please return completed forms prior to first practice to:
Kyle Roepnack ATC
Athletic Trainer's Office
Herkimer College
100 Reservoir Rd.
Herkimer NY, 13350
(315) 866-0300 ext: 8393