University of the Cumberlands
 Office of Athletic Training
7790 College Station Drive
Williamsburg , KY 40769-1390

CONTACT LENSE PRESCRIPTION FORM

The Athletic Training Department of the University of the Cumberlands is dedicated to providing the highest level of care to our athletic participants. In order to help us with this task we request that student athletes wearing contact eye correction provide us with a copy of your current lens prescription information.

 

STUDENT NAME:


SPORT
RX
BRAND
 BC DIAM. POWER
O.D. (right)
O.S. (left)
RX Expires: Last Exam:
Name of Eye Care Provider
  Office Address/City/State/Zip:
  Office Phone:

*As with other specialized athletic prescriptions we are requesting that you provide your supervising Certified Athletic Trainer (ATC) with a spare pair of your current lens prescription, which will be carried in your teams athletic training kit and available for your use in the event that you lose or damage one of your lenses during your sport activity. These lenses will be returned to you at the end of the school year.

The prescription listed above will be kept in your medical file and in the event that you need local assistance in obtaining additional lenses it will be used to help expedite the process.