2016 MEDICATION DISCLOSURE FORM

2016 MEDICATION DISCLOSURE FORM

I, ___________________________ would like to disclose the following substance for which I consume as prescribed by a medical doctor. I understand that it is my responsibility to contact the Sports Medicine Staff about any medication I am are currently taking. I am fully aware that the NCAA has a banned substance list in which prescription drugs may elicit a positive drug test. Ultimately, I am responsible for knowing what is contained in any supplement that I may take.

1. Prescription: _______________________________________________________________________ Reason: __________________________________________________________________________

2. Prescription: _______________________________________________________________________ Reason: __________________________________________________________________________

3. Prescription: _______________________________________________________________________ Reason: __________________________________________________________________________

4. Prescription: _______________________________________________________________________ Reason: __________________________________________________________________________

______________________________

_______________________________

Student-Athlete

Athletic Training Staff

Date

Date