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Intramural/Recreation User Application

Applications must be renewed each year, prior to Sept. 1. An official NCCC ID Card is required to use Intramural / Recreation facilities.

Before you can participate in any intramural and recreation activity, ALL contents of this application must be read, completed, and submitted online.

Do not fill out the form until you have read the following documents:

Your Status:  Student       Faculty       Staff       Administration       Alumni
First Name:
Last Name:
Address:
City: State:
Zip:
Home Phone:
Work Phone:
Email Address:
NCCC ID:
 
Emergency Contact: Phone:
Relationship to you:

FACILITY USE

1. I have read the "Policies and Procedures" document and I fully understand its contents. I agree to keep and obey all policies and procedures regarding the use of NCCC recreation and intramural facilities, as well as any additional or updated policies and procedures that may arise.
YES      NO

2. I have read the "Agreement for Facility Use" document and I fully understand its contents. I agree to comply with all the rules and conditions outlined therein and to keep and obey all policies and procedures regarding the use of NCCC recreation and intramural facilities, as well as any additional or updated policies and procedures that may arise.
YES      NO


HEALTH INFORMATION

1. Has your doctor ever said that you have a heart condition, high blood pressure, or heart disease?
YES      NO

2. Has your doctor ever said that you should only do physical activity recommended by a doctor?
YES      NO

3. Do you feel pain in your chest when you do physical activity?
YES      NO

4. Do you lose your balance because of dizziness or do you ever lose consciousness?
YES      NO

5. Do you have a bone or joint problem that could be made worse by a change in your physical activity? (For example: arthritis, rotator cuff problem, joint replacement)?
YES      NO

6. Is your doctor presently prescribing drugs for your blood pressure or heart condition?
YES      NO

7. If you answered yes to question #6 above, please list the name(s) of the drugs you are taking:


8. Do you know of any other reason(s) why you should not do physical activity?
YES      NO

9. Do you have any other pre-existing illnesses, diseases or conditions that would prevent you from participating in physical activity?
YES      NO


VERIFICATION

I verify that I have answered all questions to my full satisfaction and that I have read the required documents and understand the information, policies, and procedures outlined in them.
YES      NO

In lieu of a signature, we require a unique identifier. Please select the month in which you were born:

       


Questions?
Contact the NCCC Fitness Center at: (716)614-6746.

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