Health & Medical Release

  • Please complete and submit. All swimmers must have a medical release. 
  • If you have any questions, please email [email protected] or talk to a board member. 

Thank you!


Swimmer's Name: *
Guardian Email for submission confirmation:

Insurance  & Physican Information

Insurance: *
Insurance ID:*
Insurance Group:*
Enrollment Date:
Insurance Phone:

Dentist Phone:
Does the swimmer wear a dental appliance?

Does the swimmer have an eye doctor?
Eye Doctor
Eye Doctor Phone
Does the swimmer wear glasses or contacts?

Doctor Phone:*
Specialist Phone:
Specialist Area of Expertise:

Allergies and Dietary Restrictions

Does the swimmer require an EpiPen?
List Medication Allergies:
List Seasonal Allergies:
Dietary Restrictions?
List Dietary Allergies & Restrictions:
For Age Group Swimmers on Travel: May the swimmer take over-the-counter medications (e.g., Advil, Aspirin, or Tylenol)?

Medications and Treatments

It is important for our coaches to be aware of their swimmers medications and treatments in case of emergency at the practice or during travel. U.S. Anti-Doping Agency conducts testing at the national level. If a Therapeutic Use Exemption is required, it will need to be completed in advance. Thank you. 

List All Medications & Treatments:
Does your swimmer need to take medications while they travel?
Will the swimmer require medical treatment(s) while on travel (e.g., a nebulizer)?

Past History

Has the swimmer experienced an epileptic seizure or been diagnosed with epilepsy?
Has the swimmer ever been treated for diabetes?
Has the swimmer ever been treated for rheumatic fever?
Has the swimmer been diagnosed with a heart murmur?
Has the swimmer been diagnosed with asthma?
Has the swimmer experienced a concussion in the past 3 years (e.g., knocked out or bell rung)?
Has the swimmer had a fracture in the past 3 years?
If the swimmer has had a fracture(s), then list site, date, and treatment:
If the swimmer has had a concussion or head injury, then list date(s) and treatment(s) including if a hospital stay was required:
Has the swimmer experienced a neck or back injury involving nerve, vertebra, or disc?
If the swimmer has experienced a neck or back injury, then list the date(s), treatment(s) and if a hospital stay was required:
Is there a health issue, which hasn't been covered by the questions?

Medical Treatment Release

I grant permission, for my child to travel unaccompanied by a parent or guardian with NoVa Synchro coaches and approved chaperones to competitions and clinics at sites other than designated team pools during the season. the coaches or approved chaperones have the authority to see that my child has medical, dental or vision attention as needed. The swimmer's parents or guardians will pay all resulting expenses. 

Swimmer's Name - Medical Release:*
Parent's Name - Medical Release:*
Date - Medical Release:*