Medical Personnel Application | NMACT Online Forms

High School*

Medical Personnel

Name*

First Last

Email*

Cell Phone*

Role*

* Disclaimer: The NMAA Consent to Treat Policy provides parental consent for licensed Athletic Trainers (ATC), Nurse Practitioners (NP), Physicians (MD/DO), and Physician Assistants (PA) to provide sports medicine services to all NMAA-member student athletes. If your healthcare provider credentials are excluded from this list, consent has not been given to provide sports medicine services to students from another school. Additionally, your school should have a separate parental consent form on file which permits you to provide sports medicine services to their student-athletes.

Athletic Trainer (ATC)
Team Physician (MD or DO)
Advanced Practice Provider (NP or PA)

NM License Number*

Verification Statement*

I verify that the above information is correct and that I am employed/contracted by my school/district for the 2024-2025 school year. I certify that I am authorized by my school/district to provide medical care and have a current, valid license to practice in the state of New Mexico.

Medical Personnel Signature

Athletic Director

Athletic Director Name*

First Last

Athletic Director Email*

Athletic Director Phone*