Sports Medicine Registration


*All fields required.

Student Information

Location/School:
 
Last Name:
 
First Name:
 
Middle Name:
 
*Please enter NMN if you do not have a middle name.
Social Security Number:
   
*Please enter 999-99-9999 if you do not have a Social Security Number.
Sex:
 
Date of Birth:
   
Address:
 
City:
 
State:
 
Zip Code:
 
Country:
 
Email:
   
Home Phone:
 
Work Phone:
 
Mobile Phone:
 
Permanent or Temporary Address:
 

Guarantor Information (Person responsible for any medical bills)

Relationship:
 
Last Name:
 
First Name:
 
Middle Name:
 
Address:
 
City:
 
State:
 
Zip Code:
 
Country:
 
Home Phone:
 
Work Phone:
 
Mobile Phone:
 

Emergency Contact Information

Relationship:
 
Last Name:
 
First Name:
 
Middle Name:
 
Address:
 
City:
 
State:
 
Zip Code:
 
Country:
 
Home Phone:
 
Work Phone:
 
Mobile Phone:
 

Insurance Information

Insurance Company Name:
 
Address:
 
City:
 
State:
 
Zip Code:
 
Country:
 
Relationship to Subscriber:
 
Group Number:
 
Member ID Number:
 

Policy Holder's Information

Subscriber's ID Number:
 
Subscriber's Last Name:
 
Subscriber's First Name:
 
Subscriber's Middle Name:
 
*Please enter NMN if you do not have a middle name.
Subscriber's Social Security Number:
   
*Please enter 999-99-9999 if you do not have a Social Security Number.
Subscriber's Sex:
 
Subscriber's Date of Birth:
   
Subscriber's Address:
 
Subscriber's City:
 
Subscriber's State:
 
Subscriber's Zip Code:
 
Subscriber's Country:
 
         

If you have a question about the information that you are being asked for, please contact
SCAD Athletic Training Room Number – 912-525-8445
Denise Holloway – Staff Athletic Trainer – 513-252-5574
Jason Johnson – Staff Athletic Trainer – 630-664-2472
If you have a problem with the form not working, please call SupportOne at 350-8321.