1 Dear Parent/Student-Athlete: On behalf of the athletic training staff, we would like to welcome you back to MSUM Athletics. We would like to take this opportunity to remind you of some important information regarding our policies in dealing with athletic injuries. ALL STUDENT-ATHLETES ARE REQUIRED TO HAVE PERSONAL INSURANCE, EITHER THEIR OWN OR THROUGH THEIR PARENTS/GUARDIANS. The insurance MUST cover the student-athlete in Minnesota and North Dakota. MSUM ATHLETICS DOES NOT PROVIDE ANY PRIMARY OR SECONDARY ATHLETIC INSURANCE COVERAGE. The goal of MSUM s athletic training staff is to provide our student-athletes with the best possible medical care. MSUM Athletics is affiliated with Sanford Health, Fargo, ND. Student-athletes will be referred to team physicians provided by Sanford, unless their personal insurance dictates otherwise. If the student-athlete and/or parents wish to have a second opinion, that is encouraged. However, please keep in mind that the final authority for determining any student-athlete s return to play will be MSUM team physicians. Should a student-athlete incur a medical expense, the student s personal insurance will be billed. If there is an outstanding balance at that time, the student-athlete, and/or parents, will be responsible for the remaining balance. Please familiarize yourself with all requirements of the insurance policy that you carry. It is advisable to let your insurance company know that you have a dependent that will be traveling away from home so that you will be able to determine what will need to be done in the event that a claim must be filed. Please return this letter, as well as the following forms, to MSUM Athletic Training, no later than July 15, (ALL forms must be completed and on file in the athletic training room before any student-athlete is eligible for participation in any intercollegiate activity.) Physical Exam (5 th Year Seniors ONLY) Medical History Update Insurance information Copy of insurance card (front and back) Policies and Procedures ADHD form Informed and Medical Consent Second Party Information Release Concussion form Sickle Cell Trait Waiver (or test results) Substance Abuse Program Information MAIL/FAX/ ALL FORMS TO: Andrea Scott, MS, ATC Head Athletic Trainer Minnesota State University Moorhead th Ave. S. Moorhead, MN FAX Please sign this letter indicating that you have read and understand the information above, and send it with the other forms. Please feel free to contact us if you have any questions at or Student-Athlete Name: Sport: Please Print Full Name Student-Athlete Signature: Date:
2 Athletic Physical Examination (EXAMS MUST BE DONE BY A MEDICAL DOCTOR OR OSTEOPATHIC PHYSICIAN) PLEASE PRINT This form was developed in accordance with the NCAA Sports Medicine Guidelines and the AHA Recommendation for Cardiovascular Preparticipation Screening of Competitive Athletes Name Date of Exam Date of Birth Age Sex Sport Height (inches) Weight (lbs.) Brachial Blood Pressure (sitting position) Pulse Vision Right 20/ Left 20/ Hearing (Whispered voice at 10 feet) Contact Lens: Yes No Color Blind: Yes No Right: Normal Abnormal Left: Normal Abnormal Clinical Evaluation Normal Abnormal NOTES (Describe any abnormality in detail. Include results of any lab done.) 1. Scalp, Face, Neck, Thyroid 2. Nose and Sinuses 3. Mouth (tongue, gingivae, teeth) 4. Throat and Tonsils 5. Ears (tims and ext. canals) 6. Eyes (pupils, EOM conjunct.) 7. Lungs and Chest (include breasts) 8. Heart (rhythm, sounds, murmurs) a. Precordial auscultation (supine) (standing) b. Assessment of femoral artery pulses (to exclude coarctation of the aorta) c. Physical stigmata of Marfan syndrome 9. Sickle Cell Trait 10. Abdomen and Viscera 11. Hernia 12. Anus and Rectum (prostate if indicated) 13. Endocrine system 14. G-U System 15. Upper Extremity (shoulder, arm, wrist, hand) 16. Lower Extremity (hip, thigh, knee, ankle, foot) 17. Skin, Lymphatic Glands (cervical, inguinal, axillary) 18. Neurologic 19. Pelvic (if deemed necessary) Menstrual Cycle 20. Surgery(ies) 21. Other Drug Allergies, Medications currently prescribed, etc. (Over) Minnesota State University Moorhead is an equal opportunity educator & employer and is a member of the Minnesota State Colleges & Universities System.
3 Physician Recommendation Please Complete 1. Approved for athletic participation without limitation. 2. Approved for athletic participation with limitation. Specify: 3. NOT approved for athletic participation. Specify: Printed Name of Physician: Clinic Name/Facility: Street/City/State/Zip: Phone: Fax: Signature of Physician: Date Medical License #: This form must be signed by an MD or DO.
4 Returning Athlete s Medical History Update Complete the information below ONLY if you competed or participated on an MSUM intercollegiate athletic team during this past school year. Please Print Date: Name: Sport: 1. Have you had any health-related problems or seen a medical doctor since LAST MAY? q Yes q No If yes, when and for what reason? 2. Do you take any medication(s) regularly or for emergency use? q Yes q No If yes, please list the medication(s), why you take them (i.e., diabetes, asthma, bee sting, allergies), and dosage. 3. List any other medical conditions or allergies that you may have developed since last LAST MAY? 4. Review of systems: Please check if you have developed any problems with any of the following areas of your body since last LAST MAY: q Skin q Head q Lungs q Hips, knees, legs, feet q Eyes q Heart q Muscles/Tendons q Ears q Abdomen q Depression/Anxiety q Nose q Back q Other: what? q Mouth/throat q Bowel/Bladder q Nutrition/weight control q Genital (including menstrual for females) q Neck q Shoulders, elbows, hands, fingers Explain I have answered truthfully all questions and understand that withholding any history of prior illness/injury may release Minnesota State University Moorhead from any financial responsibility or legal liability for a preexisitng problem. Athlete s Printed Full Name Date Athlete s Full Signature Minnesota State University Moorhead is an equal opportunity educator and employer and is a member of the Minnesota State Colleges and Universities System. This information will be made available in alternate format upon request by contacting Disability Services at (voice) or (MRS/TTY).
5 Athletic Insurance Information Sheet PLEASE RETURN TO ATHLETIC TRAINING ROOM The following information and authorization must be completed, signed, and returned before the athlete will be allowed to participate! Athlete s Full Name Permanent Address (City/State/Zip) Sport Birthdate Phone ( ) PRIMARY INSURANCE: Policy Holder Relationship Policy Holder s Date of Birth Policy Holder s Home Address Home Telephone Number ( ) Cell Number ( ) Policy Holder s Employer s Name Employer s Address Name of Insurance Company Insurance Mailing Address ID Number Group Number Insurance Company Telephone Number ( ) Is your dependent son/daughter covered under the above policy? q Yes q No. Does your insurance require: a second opinion for surgery? q Yes q No Pre-authorization for service? q Yes q No SECONDARY INSURANCE: Policy Holder Relationship Policy Holder s Date of Birth Policy Holder s Home Address Home Telephone Number ( ) Cell Number ( ) Policy Holder s Employer s Name Employer s Address Name of Insurance Company Insurance Mailing Address ID Number Group Number Insurance Company Telephone Number ( ) Is your dependent son/daughter covered under the above policy? q Yes q No. Does your insurance require: a second opinion for surgery? q Yes q No Pre-authorization for service? q Yes q No Please indicate which of the following medical facilities in the Fargo-Moorhead area your insurance company will allow you to use. If your insurance company allows you to receive services anywhere, Sanford Clinics and Hospital will be used since our Team Physicians are affiliated with Sanford. PLEASE CHECK ALL THAT APPLY: q My insurance allows for services ANYWHERE in the Fargo/Moorhead area q My insurance allows for EMERGENCY services ONLY in the Fargo/Moorhead area q Sanford Hospital q Sanford Clinics q Essentia Health q Fargo-Moorhead Area Independent Physician (Please list below) Name/Clinic (Over)
6 Please Note: You may want to consider transferring your medical insurance coverage to the Fargo/Moorhead area while you are participating in intercollegiate athletics. If you are from out-of-town, many HMO s or PPO s will only cover medical expenses within your local region. This often becomes inconvenient for the student-athlete when he/she has to travel to hometown hospitals or clinics. Authorization, Agreement, Consent, Release and Indemnification I hereby authorize Minnesota State University Moorhead to inspect or secure copies of case history records, laboratory reports, diagnoses, x-rays and/or any other data covering this and/or previous confinements and/or disabilities. I understand the risks of injuries and losses that can occur as a result of participating in intercollegiate athletic activities and assume all such risks. I hereby allow Minnesota State University Moorhead s Athletic Medical Staff to administer whatever medical treatment and/or care deemed necessary for the health and well-being of myself. Furthermore, I consent to have administered to me any emergency medical or surgical treatment recommended by any licensed physician In consideration of the student athlete being permitted to participate in Minnesota State University Moorhead s Intercollegiate Athletic Program. I release and agree to idemnify and hold harmless Minnesota State University Moorhead, its Board, president, officers and employees against and from any and all claims, damages and expenses arising out of or resulting from such injuries, losses and medical treatment or care. A photostatic copy of this authorization shall be deemed as effective and valid as the original. I understand that if my insurance lapses during the school year, or athletic season(s), that I am responsible for any and all bills related to athletic injuries occurring during that time. Date: Signature of Custodial Parent/Legal Guardian (if athlete is under 18 years of age) Date: Signature of Student-Athlete Please submit a photocopy of your insurance card to accompany this form. We must have copies of BOTH sides of the card. You will not be allowed to participate without a copy of your card on file! Minnesota State University Moorhead is an equal opportunity educator & employer and is a member of the Minnesota State Colleges & Universities System.
7 MINNESOTA STATE UNIVERSITY MOORHEAD ATHLETIC TRAINING MEDICAL PROCEDURES I. Mandatory Physical Examinations: A. Every new student-athlete must have a physician-approved physical examination on file with the athletic training department prior to any participation in conditioning, practice, or game. Student-athletes must have a new physical exam done every four years. If you participated at MSU Moorhead in athletics, and then sat out one or more semesters, you must have an updated physical examination. B. Student-athletes must complete the athletic medical forms and submit them to Andrea Scott, Head Athletic Trainer, Minnesota State University Moorhead, Moorhead, MN II. Reporting Injuries: A. Report all injuries, cuts, abrasions, etc., immediately after participation. Infections can be held to a minimum by early treatment. If you are injured during participation, contact the athletic trainer immediately. The athletic trainer will take whatever steps are necessary. B. The head coach will be notified of the student-athlete's injury or illness. C. As members of an MSUM athletic team it is the responsibility of the student-athlete to report to the athletic training room for injury evaluation, treatment, and rehabilitation. If further referral is needed, the athletic training staff will give assistance. III. Evaluating Injuries: A. Injured student-athletes will be evaluated immediately by an athletic trainer or athletic training student. B. The student-athlete may be referred to the athletic training room for treatment, to a physician or to Hendrix Clinic and Counseling Center for additional evaluation. (also see V.B) C. If the student-athlete needs to see a physician, the athletic trainer will make the necessary arrangements. D. After approval by the team physician and/or a certified athletic trainer, the studentathlete will return to practice and/or competition. MSUM team physicians have final approval on whether a student-athlete is cleared for participation. E. The head coach will be notified of all injuries/illnesses pertaining to his/her respective student-athletes. IV. Illness: A. In case of illness, contact the athletic trainer prior to noon of each day. B. The Hendrix Clinic and Counseling Center is open 8:00am-4:30pm Monday through Friday during fall and spring semesters. Any student who has paid activity fees is eligible to use Hendrix Clinic and Counseling Center. (There is no charge to see a doctor.) If referred to a physician or to Hendrix Clinic and Counseling Center by an athletic trainer, the athlete must have an Athletic Medical Referral Form. This form is to be completed by the attending physician and/or a nurse practitioner, and returned to the athletic trainer before athletic participation can be resumed. C. Any medication(s) prescribed by a physician is/are at the expense of the studentathlete...not THE MSUM ATHLETIC DEPARTMENT!
8 V. Medical Expenses: A. MSUMDOES NOT provide any primary or secondary athletic insurance. All studentathletes must be insured, either under their parents/guardians or a personal insurance policy. All expenses related to athletic injuries will be billed to the student-athletes insurance. Any bills not covered by insurance will be the responsibility of the studentathlete and/or parents/guardians. 2 B. If a student-athlete desires to seek medical care/treatment other than through the MSUM athletic medical staff, he/she must be cleared by the athletic training staff prior to receiving the care and treatment. This is to insure that the necessary insurance paperwork and injury reports are completed BEFORE the appointment(s) so appropriate care is provided once a diagnosis is received. ATHLETIC TRAINING ROOM RULES 1. The athletic training room is open Monday through Friday from 1:00 to 6:00pm. Morning hours are by appointment only. 2. All treatments, taping, medications, and consultations given after practice are done AFTER SHOWERING. 3. No shoes will be allowed in the athletic training room area. 4. Athletic equipment (football pads, cleats, spikes, etc.) is to be kept out of the athletic training room. 5. Athletic training towels are to remain in the athletic training room. Towels are not to be used for any purpose other than treatments. 6. Supplies/equipment will be dispensed/operated by athletic training staff only. 7. This is the MEDICAL CENTER for MSUM Athletics. Horseplay, profanity, use of tobacco, food, and drinks are not allowed while receiving treatments. 8. The athletic training room is co-ed. Shorts and t-shirts are required. 9. In-season, injured student-athletes have priority in receiving treatments. The athletic training staff reserves the right to schedule treatment times. 10. Athletes injured and unable to practice should check with the athletic trainers daily for prescribed activities/rehab. 12. Give respect, receive respect, and respect the athletic training staff. EMERGENCY TELEPHONE NUMBERS Hendrix Clinic and Counseling Center Sanford Health Medical Center Emergency Room MSUM Athletic Training Room Office or (Andy, Ronda, Keith, Chuck) Head Athletic Trainer Andrea Scott (C) Assistant Athletic Trainer Ronda Peterson (C) Assistant Athletic Trainer Keith Wiedrich (C) Assistant Athletic Trainer Charlie Meek (C) Assistant Athletic Trainer Erin Heine (C) Assistant Athletic Trainer Eric Lundberg (C) 2
9 PLEASE KEEP THE ATHLETIC TRAINING MEDICAL PROCEDURES AND ATHLETIC TRAINING ROOM RULES FOR FUTURE REFERENCE WHILE AT MSU MOORHEAD 3 MINNESOTA STATE UNIVERSITY MOORHEAD Athletic Training Medical Procedures and Athletic Training Room Rules Signature Form I have received, read, and fully understand the Minnesota State University Moorhead Athletic Training Medical Procedures and Athletic Training Room Rules, and will comply with them. PLEASE PRINT ATHLETE'S FULL NAME: (first) (middle) (last) SIGNATURE: (full name) SPORT: DATE: IF STUDENT-ATHLETE IS UNDER 18 YEARS OF AGE Parent/Guardian Signature is Required PARENT'S/GUARDIAN'S SIGNATURE: DATE: (revised 4/15) 2
10 Minnesota State University Moorhead Information Regarding the Use of Banned Stimulants for Treatment of ADHD, ADD and/or like conditions. Background The NCAA bans classes of drugs that can be harmful to student- athletes and that can create unfair advantages during completion (NCAA Bylaw ). Some medications that student- athletes are prescribed for legitimate medical reason contain NCAA banned substances. Effective August 1 st, 2009, with respect to the use of banned stimulant medication used to treat Attention Deficit Hyperactivity Disorder (ADHD), Attention Deficit Disorder (ADD), and/or like conditions, (e.g. Ritalin, Strattera, Adderall, Concerta, etc.) the NCAA now requires documentation of a compressive clinical evaluation to support treatment with NCAA banned stimulants and a current prescription. Who to contact if prescribed stimulant medications for ADHD, ADD, and/or like conditions. Student- athletes who have been prescribed stimulant medications for the treatment of ADHD, ADD, and/or like conditions should immediately notify a member of the athletic training department to ensure that they have the necessary documentation on file. What documentation must the student- athletes obtain from his/her prescribing physician? At a minimum, student- athletes prescribed NCAA banned stimulants for the treatment of ADHD, ADD, and/or like conditions must provide the following documentation from the prescribing physician: 1. Evidence of comprehensive clinical evaluation (recording observations and results from standardized rating scales and/or neuropsychological testing), a physical exam and any lab work (attaching all documentation); * A simple statement from a prescribing physician that he/she is treating the student- athlete for ADHD, ADD, and/or like conditions with the prescribed stimulant IS NOT adequate documentation. 2. Statement of diagnosis, including when diagnosis was confirmed. 3. History of ADHD, ADD, and/or like conditions treatment (previous and ongoing). 4. Recommended treatment (attaching current prescription). 5. Statement that a non- banned ADHD alternative has been considered and why banned stimulant was prescribed. 6. Annual follow up with prescribing physician and updated letter of copy of medical record is required in each year of eligibility. When and where should documentation be sent? Andrea Scott Minnesota State University Moorhead th Ave S. Moorhead, MN If your son/daughter s physician needs a sample evaluation form or more detail on the information needed for the documentation, please feel free to contact me. Also, if you have any other questions please do not hesitate to me. Andrea Scott, MS, ATC Phone:
11 Minnesota State University Moorhead ADHD Medical Exceptions Notification Form I, affirm that I have been informed by Minnesota State University Student- Athlete Print Name Moorhead athletic training personnel on this date, about NCAA Banned Substances List and NCAA Medical Exceptions Policy as it specifically pertains to the use of banned stimulant medications (e.g. Ritalin, Strattera, Adderall, Concerta, etc.) that are used to treat Attention Deficit Hyperactivity Disorder (ADHD), Attention Deficit Disorder (ADD), and or/like conditions. I attest that: Initial Initial I AM NOT presently taking and/or have taken within the last 12 months any banned stimulant medications (e.g. Ritalin, Strattera, Adderall, Concerta, etc.), that are used to treat Attention Deficit Hyperactivity Disorder (ADHD), Attention Deficit Disorder (ADD), or like conditions. I AM presently taking and/or have taken within the last 12 months banned stimulant medications (e.g. Ritalin, Strattera, Adderall, Concerta, etc.), that are used to treat Attention Deficit Hyperactivity Disorder (ADHD), Attention Deficit Disorder (ADD), or like conditions. I, the undersigned, do hereby affirm that I understand that I am to immediately notify a member of the Minnesota State University Moorhead athletic training department should I ever be prescribed the aforementioned stimulant medications and that I must obtain and submit appropriate documentation from the prescribing physician. I further attest that I have had any and all questions regarding the NCAA ADHD Medical Exceptions Policy answered to my satisfaction. Student- Athlete Signature Date Student- Athlete Print Name Athletic Trainer Print Name Date
12 TO ALL ATHLETIC TRAINERS AND MEDICAL PERSONNEL Athletic Training SECOND PARTY INFORMATION RELEASE AUTHORIZATION on the Minnesota State University Moorhead staff, including full-time, part-time, and consultants: You are authorized to provide to my parents or guardians and to scouts, coaches, the media, University personnel and medical personnel, information concerning my health care, injury, rehabilitation, treatment, and health status. This information is to be used for the purpose of advising persons of my health or injury status. You are also authorized to obtain medical information and records from all of my past or present health care/medical treatment providers. This authorization is valid while I am a student at Minnesota State University Moorhead. A photographic copy of this authorization is valid as the original. Date: Signature Printed or Typed name Birthdate If you are under the age of 18 a parent or guardian must sign this form: Date: Signature of Parent or Legal Guardian Printed or Typed name Address of Parent or Legal Guardian Address of Parent or Legal Guardian Minnesota State University Moorhead is an equal opportunity educator & employer and is a member of the Minnesota State Colleges & Universities System. This information will be made available in alternate format, such as Braille, large print or audio cassette tape, upon request by contacting Disability Services at (voice) or (MRS/TTY).
13 Athletic Training Informed and Medical Consent Form Please read, sign and return to us the following consent form. If you are under 18 years of age, your parents/guardians must also sign. If you should choose to refuse to sign this consent form, please write Refused to sign, the date, and your signature on the appropriate line. Informed and Medical Consent I, (print name), am aware that trying out, practicing, or playing in any sport can be a dangerous activity involving many risks or injury. I understand that the dangers and risks include, but are not limited to, death, serious head, neck and spinal injuries, paralysis, injuries or impairment to the musculoskeletal system, or other aspects of the body, general health, and well-being. Because of the dangers of participating in sports, I recognize the importance of following the instructions of the athletic department personnel regarding playing techniques, training, rules of the team/sport, equipment, and to obey such rules. I also acknowledge that some sports are classified as collision sports involving even a greater risk of injury than other sports. I further realize that I am expected to report all injuries/illnesses I may have sustained during periods of official, organized athletic participation (including all regularly scheduled practices and contests) and throughout the calender year, (regardless of how they occurred) to a coach, to an athletic trainer, or to a team physician. I hereby grant permission to the Minnesota State University Moorhead Team Physicians and/or their consulting physicians to render to myself (son/daughter) any treatment, medical or emergency surgical care that they deem reasonably necessary to the health and well-being of the student-athlete. I also hereby authorize the Minnesota State University Moorhead Athletic Trainers, and their staff, who are under the direction and guidance of the Minnesota State University Moorhead Team Physicians, to render to myself (son/daughter) any preventive measures for injuries, first aid, treatment, rehabilitation, or emergency treatment that they deem reasonable and necessary to the health and well-being of the student-athlete. This includes all practices, games, and travel. When necessary for executing such case, I grant permission for hospitalization at an accredited hospital. (Signature may be that of the student-athlete over 18 years of age; if under 18 this form must also be signed by a parent or guardian.) Date Signature of Athlete Printed or Typed Name Signature of Parent or Legal Guardian Printed or Typed Name Address of Parent or Legal Guardian Address of Parent or Legal Guardian Date
14 CONCUSSION A FACT SHEET FOR STUDENT-ATHLETES WHAT IS A CONCUSSION? A concussion is a brain injury that: Is caused by a blow to the head or body -From contact with another player, hitting a hard surface such as the ground, ice or floor, or being hit by a piece of equipment such as a bat, lacrosse stick or field hockey ball. Can change the way your brain normally works. Can range from mild to severe. Presents itself differently for each athlete. Can occur during practice or competition in ANY sport. Can happen even if you do not lose consciousness. HOW CAN I PREVENT A CONCUSSION? Basic steps you can take to protect yourself from concussion: Do not initiate contact with your head or helmet. You can still get a concussion if you are wearing a helmet. Avoid striking an opponent in the head. Undercutting, flying elbows, stepping on a head, checking unprotected opponent, and sticks to the head all cause concussions. Follow your athletic department s rules for safety and the rules of the sport. Practice good sportsmanship at all times. Practice and perfect the skills of the sport. WHAT ARE THE SYMPTOMS OF A CONCUSSION? You can t see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. Concussion symptoms include: Amnesia. Confusion. Headache. Loss of consciousness. Balance problems or dizziness. Double or fuzzy vision. Sensitivity to light or noise. Nausea (feeling that you may vomit). Feeling sluggish, foggy or groggy. Feeling unusually irritable. Concentration or memory problems (forgetting game plays, facts, meeting times). Slowed reaction time. Exercise or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games may cause concussion symptoms (such as headache or tiredness) to reappear or get worse. WHAT SHOULD I DO IF I THINK I HAVE A CONCUSSION? Don t hide it. Tell your athletic trainer and coach. Never ignore a blow to the head. Also, tell your athletic trainer and coach if your teammates might have a concussion. Sports have injury timeouts and player substitutions so that you can get checked out. Report it. Do not return to participation in a game, practice or other activity with symptoms. The sooner you get checked out, the sooner you may be able to return to play. Get checked out. Your team physician, athletic trainer, or health care professional can tell you if you have a concussion and when you are cleared to return to play. A concussion can affect your ability to perform everyday activities, your reaction time, balance, sleep, and classroom performance. Take time to recover. If you have a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have a repeat concussion. In rare cases, repeat concussions can cause permanent brain damage, and even death. Severe brain injury can change your whole life. I understand that I am responsible for reporting all injuries and illnesses to the MSUM Athletic Training staff, including the signs and symptoms of concussions, and I acknowledge that the MSUM Athletic Training staff has educated me on concussions. Student-Athlete Signature Parent/Guardian Signature (if athlete is younger than 18 years of age) Date Date
15 Sickle Cell Trait Waiver NCAA regulations now recommend that all incoming student-athletes be tested for sickle cell trait. Results from a previous test or a signed waiver are alternatives to testing. However, test results or a signed waiver MUST be turned in to the athletic training department before student-athletes will be allowed to participate in any athletic activity. Please read the information below and speak to your health-care provider to determine if you are at risk of having sickle cell trait. What is sickle cell trait? Sickle cell trait is not a disease. Sickle cell trait is the inheritance of one gene for sickle hemoglobin and one for normal hemoglobin. Sickle cell trait will not turn into the disease. Sickle cell trait is a life-long condition that will not change over time. During intense exercise, red blood cells containing the sickle hemoglobin can change shape from round to quarter moon, or sickle. Sickle red cells may accumulate in the bloodstream during intense exercise, blocking normal blood flow to the tissues and muscles. During intense exercise, athletes with sickle cell trait have experienced significant physical distress, collapsed and even died. Heat, dehydration, altitude and asthma can increase the risk for and worsen complications associated with sickle cell trait, even when exercise is not intense. Signs of sickling include fatigue, difficulty breathing, leg or low back pain, and sudden weakness. Athletes with sickle cell trait should not be excluded from participation as precautions can be put into place. Who is at risk for sickle cell trait? Although sickle cell trait is most predominant for those whose ancestors come from Africa, South or Central America, India, Saudi Arabia and Caribbean and Mediterranean countries, persons of all races and ancestry may test positive for sickle cell trait. Sickle cell trait occurs in about 8 percent of the U.S. African American population, and between one in 2,000 and one in 10,000 in the Caucasian population. Most U.S. states test at birth, but most athletes with sickle cell trait don t know they have it. Please contact MSUM Athletic Training at if you have any questions. I, understand that NCAA regulations recommend that all incoming student-athletes be tested for sickle cell trait. For, and in consideration, of my being allowed to participate in college athletics at Minnesota State University Moorhead, I accept any and all risks of harm that may result from this voluntary decision. I further release, hold harmless and agree to indemnify the State of Minnesota, Minnesota State University Moorhead, and/or their respective employees from any and all liability for claims stemming from this decision, including but not limited to, any and all risk of injury, sickness, disease or any other harm, and I further certify that I will not seek compensation or legal relief in the event I suffer illness or injuries due to my decision not to be tested for sickle cell trait. I further certify that I am of legal age (18 years or older) and am under no legal disability that would interfere with my ability to knowingly sign and execute this consent and waiver form. Student-Athlete Signature Date Parent/Guardian Signature (if under 18 years of age) Date
16 MINNESOTA STATE UNIVERSITY MOORHEAD ATHLETICS SUBSTANCE ABUSE PROGRAM A. INTRODUCTION: As an institution of higher learning, Minnesota State University Moorhead has committed itself to enriching the lives of its students through both classroom activities and campus cultural programs. It is hoped that these experiences will enhance the development of responsible behavior in students academic lives and their social activities. It is evident that the abuse of alcohol or any other drugs will always minimize student s abilities to develop academic potential or social relationships. According to Minnesota State University Moorhead s Substance Use and Abuse Policy in the Student Handbook, alcoholic beverage and drugs are not permitted on the campus of Minnesota State University Moorhead. The unlawful use, possession or distribution of alcoholic beverages or illegal drugs at University sponsored events, on- or off-campus, is prohibited by federal and/or Minnesota State Law (Section 340A). The following is an outline of the drug screening and testing guidelines for the duration of the studentathlete s eligibility at Minnesota State University Moorhead. The student is expected to cooperate in the administration of this policy and its guidelines. Refusal to cooperate will result in suspension from participation in athletically-related activities; therefore, discontinuance of any athletically-related financial aid at the beginning of the next semester. The policy applies to all male and female intercollegiate varsity and junior varsity team members, cheer team, athletic student trainers and student managers. B. PURPOSE: 1. To establish and provide an informative program to help educate student-athletes on the potentially adverse affects of chemical substances. The program will involve representatives of the health care profession known to be qualified in the areas of drug usage and abuse. 2. To utilize reputable testing methods proven effective in the identification of persons who abuse the use of chemical substances. 3. To establish an eligibility policy for student-athletes who do not comply or who do test positive. 4. To identify and provide a channel of education, counseling, and rehabilitation for the studentathlete with a chemical abuse or dependency problem. C. IMPLEMENTATION: During the academic year, a presentation will be made to each sport by the Head Coach or Athletic Trainer outlining the University s Substance Abuse Program. A copy of the policy will be given to each student-athlete. Each athlete will be asked to: 1. Sign a statement acknowledging receipt of a copy of the policy. 2. Execute involuntary consent to the screening/testing required by the program. 3. Sign a statement authorizing release of results to: Director of Athletics/Head Coach/Head Athletic Trainer, Hendrix Health Center Director (HHCD), Chemical Health Educator/Licensed Addiction Counselor (CHE/LAC). 1
17 D. EDUCATIONAL REQUIREMENT: The NCAA requires that all student-athletes complete a minimum alcohol and drug education program. At MSUM, that requirement will be fulfilled by attending several different meetings, presentations, and possibly an on-line educational program. E. SCREENING AND ASSESSMENT: All athletes will participate in a substance abuse screening program coordinated by the Head Athletic Trainer and Hendrix Health and Counseling Director and HHC Lab. This will include but not be limited to written, computerized or verbal assessment. Failure to comply with established screening policy would mean loss of eligibility to practice or participate in their respective sport. PROCEDURE: Athletic Coaches will meet with their respective teams early in their seasons to review the Minnesota State University Moorhead Athletics Substance Abuse Program. This must be reviewed prior to the athletes attending the seminar and completing the screening test. Studentathletes are required to attend one educational seminar and complete the written screening test. F. REFERRAL: Athletes unable to attend the seminar and screening sessions established will be required to make an appointment with the Head Athletic Trainer to have screening completed. The Head Athletic Trainer will provide the HHCD with a current team roster of freshmen and transfer student athletes. The CHE/LAC will 1) verify that each athlete on the roster has completed screening and 2) notify each of those athletes failing to complete screening and of those in need of follow-up appointments. Results of the screening will be reviewed by the CHE/LAC. Those athletes whose screening indicate that they are at high risk for problems related to their substance use will be required to make an appointment with the CHE/LAC for further review and assistance. (The contents of these sessions are confidential between the athlete and the CHE/LAC). Students who demonstrate signs of problems with substance use will be referred to the CHE/LAC. Indicators which may be used in the evaluation of a students behavior include: class attendance record, significant GPA changes, practice attendance record, performance and health changes, motivation level regarding academic and athletic activity, emotional condition, mood swings, legal involvement, and extreme misconduct involving substance abuse or alcohol consumption. The Director of Athletics, Head Coach, Head Athletic Trainer or CHE/LAC can require student-athletes to report to the Hendrix Health and Counseling Center for assessment and possible testing. 2
18 G. TESTING: Minnesota State University Moorhead reserves the right to administer laboratory tests according to the following guidelines. The HHCD will be responsible for the supervision of all testing. Evidence for the following substances may be tested: amphetamines, barbiturates, benzodiazepines, opiates, cocaine, THC, PCP, LSD, alcohol and anabolic steroids. Athletes taking medication under a doctor s guidance will be given special consideration. Cases of this type should be brought to the attention of the HHCD. 1. PROCEDURE: Student-athletes may be referred for unannounced testing should those previously stated behavior indicators be identified by the Director of Athletics, Head Coach, Head Athletic Trainer, or CHE/LAC for probable cause. Student-athletes will be asked to sign an Informed Consent waiver giving Hendrix Health Center (HHC) permission to test upon referral or at announced times during the year. Under the supervision of the HHCD urine samples will be collected for analysis by the HHC Lab who will send sample to reference lab for screening. Samples will be tested first by Immunoassay Screening, and, if necessary, further tested utilizing Gas Chromatography/Mass Spectometry. Identification of those participating in the urinalysis, and the results will be strictly confidential. The testing service will notify the HHCD of all results. 2. COLLECTION PROTOCOL: a. Identification labels are made in duplicate by HHC. b. Team roster identifying persons submitting to drug screening is supplied by the athletic department and taken to HHC. c. Urine collection bottles are supplied by HHC. d. The collection must be an observed catch by a member of the HHC or Athletics staff. e. Collection of specimens obtained in a bathroom at HHC. f. Athlete deposits specimen in container and caps container. g. Athlete removes two labels containing same number, places one label on container, and the other by corresponding name on roster. h. Container and identification number are placed in plastic bag and sealed. 3. IDENTIFICATION AND SHIPMENT PROTOCOL a. Sealed containers are placed in shipment box by HHCD to be stored in refrigeration before courier from testing agency picks up shipment. b. Shipment is picked up by courier and transported to testing lab. c. Results are sent by courier to HHC Director and HHC Lab. d. HHC Director and HHC Lab matches test results with identification. e. HHC Director sends letters to all tested athletes and respective coach, Head Athletic Trainer, and Director of Athletics. f. Upon positive test results, athletes are requested to contact CHE/LAC for individual appointment (or whatever is decided). g. Upon failure of athlete to contact CHE/LAC within one week, HHCD will notify appropriate Head Coach, Head Athletic Trainer, and the Director of Athletics that athlete has failed to comply with the testing program. 3
19 4. RESULTS All student-athletes tested will be notified of his/her test results in a letter from the HHCD. The appropriate Head Coach, Head Athletic Trainer and Director of Athletics will also be notified. PHASE I: If a student-athlete tests positive, and Substance Abuse Appeals Committee (SAAC, comprised of a licensed physician, the CHE/LAC, HHCD and the Head Athletic Trainer) will immediately decide if it is safe for the student-athlete to participate in practice or competition. In addition, the student-athlete will be required to 1) submit to a follow-up urinalysis, the time to be determined by SAAC, 2) make an appointment with the SEC for further assessment and counseling, and 3) make an appointment with their head coach. PHASE II: Student-athletes testing positive a second time will be notified by letter. The studentathlete will be directed by the CHE/LAC to an appropriate drug education class and/or chemical dependency evaluation facility at the student s expense. The student may not participate in practice and competition until testing negative, complying with the recommendations of the CHE/LAC and receiving approval from SAAC. PHASE III: In the event a student-athlete again tests positive, he/she remains ineligible, pending successful completion of the requirements of Phase II. That student-athlete will be subject to random urine screening at his/her expense. H. ELIGIBILITY: 1. The athlete s eligibility requirements are those specified by the NCAA, NSIC, the Head Coach of his/her sport, and the Head Athletic Trainer 2. The athlete will be required to participate in the Substance Abuse Program as defined by University policy. 3. Failure to comply with any of the above requirements may deem an athlete ineligible for participation. I. REINSTATEMENT/APPEALS: A student-athlete who has been suspended from athletic participation may petition the Substance Abuse Appeals Committee. SAAC is made up of a licensed physician, the CHE/LAC, HHCD, and the Head Athletic Trainer. Reinstatement of the student-athlete to participate in athletics may be made only after they provide satisfactory proof of the successful completion of a certified rehabilitation program and proof that their system is tested clear of drugs. 4
20 Consent to Participate in MSUM Intercollegiate Athletics Substance Abuse Program To: Hendrix Health and Counseling Center Director Chemical Health Educator/Licensed Addiction Counselor I, hereby acknowledge that I have received a copy of the MSUM Athletics Substance Abuse Program. I further acknowledge that I have read the Policy, that it has been outlined to me, and that I fully understand the provisions of the Policy. I hereby voluntarily and without threat, inducement or compulsion, consent to have a sample of urine collected and tested for the presence of certain drugs or substances in accordance within the Substance Abuse Program, at such times as required under that program. I further authorize you to make a confidential release to my Head Coach and the Athletic Director, where appropriate under the Substance Abuse Program, or screening/testing results and/or of any failure on my part to comply with the requirements of the Substance Abuse Program. I understand that the screening laboratory shall release the results of the urinalysis to the HHC Director. I hereby release the Minnesota State Colleges and University System, Minnesota State University Moorhead, its employees and agents from legal responsibility or liability for the disclosure or release of any information from the records or forms kept pursuant to this policy. (Student s Full Name PRINTED) (Date) (Student s Full Signature) (Date) (Co-signature of Parent or Guardian if student is under 18 years of age) 5
PHYSICAL EXAMINATION FORM (ATHLETE) To be filled out by Health Care Provider All full-time, undergraduate students must have a physical exam. PERSONAL DATA Name: Last First Middle Birthdate: Height: Weight:
Julie Campbell Director of Sports Medicine (303) 871-3918 Office (303) 871-3666 Fax firstname.lastname@example.org To: Re: Returning Student-Athletes 2014-2015 Sports Medicine Medical Information Packets Date: Thursday,
UNIVERSITY OF THE INCARNATE WORD SPORTS MEDICINE DEPARTMENT Release and Waiver of Liability, Assumption of Risk, Indemnity and Hold Harmless Agreements The signed student-athlete is enrolled at the University
Portland State University Sports Medicine Returning Student Athlete Health Report Form All the following forms must be completed and submitted to the Sports Medicine Department annually. It needs to be
Attention: Returning Student-Athletes Academy of Art University Sports Medicine Returning Student-Athlete Physical Packet On Behalf of the Sports Medicine Department, we look forward to another healthy
Student-Athlete Information NEW STUDENT-ATHLETE MEDICAL HISTORY FORM Name Date Birth SSN Sport Student ID Number Academic Class 1 Personal Physician s Name Phone # Person to Contact In The Event of Emergency
ELMIRA COLLEGE SPORTS MEDICINE INFORMATION, POLICY AND PROCEDURE MANUAL FOR ATHLETES Medical Eligibility for Freshman and Transfer Students: All students who wish to participate in intercollegiate athletics
Student-Athlete Insurance Information Form PLEASE INCLUDE A COPY OF YOUR INSURANCE CARD (BOTH SIDES) PLEASE PRINT ALL INFORMATION CLEARLY AND COMPLETELY! Student-Athlete s Name: SS# - - DOB / /19 (mm/dd/year)
Concussion Information Sheet A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force
Emergency Form and Medical History LAST NAME: FIRST: M.I. SEX: MALE FEMALE Date of Birth: / / Sports: Grade: School: SSN: Parent/Guardian Home Phone Cell Phone Work Phone Emergency Contact-In the event
Athletic Training Department * 320 S. Main St. * Olivet, Michigan 49076 * Fax (269)-749-4144 Dear Student-Athlete and Parent(s)/Guardian(s): On behalf of the Olivet College Athletic Training Department,
Dear Potomac State College Student Athletes and Parents: We are please to have your son/daughter as a student athlete at Potomac State College of West Virginia University and hope that he/she will achieve
June 1, 2015 The Fairfield University Sports Medicine Department requires that all student athletes complete several forms before they are eligible to participate with their athletic team in the upcoming
BOSTON UNIVERSITY DEPARTMENT OF ATHLETICS DRUG TESTING AND EDUCATION POLICY Boston University supports the National Collegiate Athletics Association s policy regarding alcohol abuse and the use of banned
2015-16 CHECKLISTS OF ATHLETIC TRAINING INFORMATION Returning GCU Student Athletes: Until these forms are complete and you have been released to practice by the Athletic Training Staff, you will not be
Texas Association of Private and Parochial Schools P.O. Box 1039 601 N. Main Salado, Texas 76571 Date: April 1, 2014 254-947-9268 254-947-9368 (Fax) To: Head Administrators Athletic Directors Coaches Parents
Concussion Information Sheet A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force
UALR Sports Medicine PLEASE READ AND FOLLOW ACCORDINGLY Dear Parent or Guardian: Enclosed is important information regarding athletic accident insurance that requires your immediate attention and response.
LEES-MCRAE COLLEGE HISTORY FOR ANNUAL CHECK-UP Pages 1 & 2 are to be completed by the student-athlete and/or his/her parent/guardian and taken along with page 3 to physician or health care professional
WEBER STATE UNIVERSITY SPORTS MEDICINE INTERCOLLEGIATE ATHLETICS DRUG ABUSE PROGRAM The department of intercollegiate athletics at Weber State University its coaching personnel and administrators, strongly
Dear Student-Athlete, Welcome back to Western Illinois University! The Sports Medicine Department provides comprehensive medical care for injuries and illnesses suffered while competing as a WIU student-athlete.
CENTRAL COLLEGE PARENT/GUARDIAN/STUDENT INFORMATION FORM 2013-2014 RETURN COMPLETED FORM TO Central College Attn: Frank Neu Campus Box 6600, 812 University St. Pella, IA 50219 If you are filling this out
Arcadia University Medical Clearance Packet 2015-16 - In order to participate in intercollegiate athletics at Arcadia University, every student-athlete must have a YEARLY pre-participation physical completed
1 Dear Returning YHC Student-Athlete and Parents/Guardians, As a Young Harris College student-athlete, we certainly hope that medical treatment for a serious injury is not necessary, but in the event that
STUDENT-ATHLETE DRUG EDUCATION AND TESTING POLICY I. INTRODUCTION. The overall goal of Rogers State University's Student-Athlete Drug Education and Testing Policy is to promote a year-round drug free environment
2016 s June 13-17 June 27-July 1 July 11-15 Held at the University of South Alabama Ages 7-13 Location: Stanky Field on the campus of the University of South Alabama Dates: June 13-17 June 27-July 1 July
FURMAN UNIVERSITY SPORTSMEDICINE CENTER IMPORTANT INSURANCE INFORMATION Dear Parents: Furman University provides an excess coverage policy for our intercollegiate athletes. Incurred medical charges are
SPORT (s): NAME: (PRINT) First Last College M#: MONTGOMERY COLLEGE SPORTS MEDICINE PACKET INSTRUCTIONS: - 7/11 - DO NOT remove any papers this includes the four physical exam pages! - If downloading from
UNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM Event Name: Dates: Participant Name: Participant cell phone with area code: Custodial Parent/Guardian Name: Phone number: Cell phone: Home
Solano College Sports Medicine Program Mission: Our mission is to care for and treat all in-season (as described by CCCAA), Solano College Athletes, and their athletic injuries. Solano College Sports Medicine
2015-16 Point Park University Athletics Medical Packet Enclosed you will find many of the necessary forms needed to compete in intercollegiate athletics during the 2015-16 year. Please return all completed
Dear Student-Athlete, Welcome back to Western Illinois University! The Sports Medicine Department provides comprehensive medical care for injuries and illnesses suffered while competing as a WIU student-athlete.
Dear Alderson Broaddus Student-Athlete: Welcome back for another exciting year at Alderson Broaddus University! In preparation for the beginning of the academic year, and your participation in intercollegiate
IU Sports Medicine Information Sheet SPORTS MEDICINE PROGRAM A. MEDICAL SERVICES The sports medicine program at Indiana University works under the direct supervision of the team physician who is located
PARTICIPANT AGREEMENT RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT I, the undersigned, on behalf of my minor child: ( Participant ), hereby acknowledge that Participant has
Ohio Valley University Athletic Department Medical Information & Health Insurance Information Packet READ OVER THIS ENTIRE CHECKLIST Page 2 (Physical Examination Form): Page two of this packet is the ONLY
Sports: Student ID#: SANTA PAULA HIGH SCHOOL Sports/Co-curricular Participation Screening Examination Name Birth Date Current Grade Home Address Home Phone Parent(s)/Guardian(s) Name Have you ever (Circle
Substance Abuse Program for Student-Athletes The abuse and misuse of drugs and alcohol is a major problem for all segments of contemporary American society. Student-athletes aren t necessarily more likely
GEORGE MASON UNIVERSITY Intercollegiate Athletics Drug and Alcohol Education and Testing Program POLICY I. PURPOSE The Department of Intercollegiate Athletics at George Mason University (GMU) is concerned
SPORTS INSURANCE PROPOSAL FORM (All questions must be answered in ink) Hanleigh Management Inc. Hanleigh Management, Inc., Hanleigh General Agency, Inc. 50 Tice Blvd., Suite 122, Woodcliff Lake, New Jersey
Warrior Sports Medicine On behalf of Warrior Athletics we would like to welcome Student Athletes and their families to the 2013-2014 Academic Year. Please take the time to read this information so that
Purpose: University of Notre Dame Sports Medicine Department Intercollegiate Athletics Concussion Management Plan Head injuries can pose a significant health risk for student-athletes competing in intercollegiate
Alabama A&M University Sports Medicine Athletic Injury and Medical Policy General Policies: A comprehensive Sports Medicine Program of prevention, treatment, and rehabilitation has been developed to ensure
BLINN COLLEGE ADMINISTRATIVE POLICY/PROCEDURE MANUAL SUBJECT: Athletic Department Drug EFFECTIVE DATE: 9-14-10 Testing Policy and Procedure REVISION DATE: 8-28-12 The Blinn College Administration and the
Saint Joseph s University Department of Athletics Drug and Alcohol Education & Testing Program 1. Introduction The following policy statement has been adopted and shall be administered by the Saint Joseph
SPORTS MEDICINE PARTICIPATION PACKET INSTRUCTIONS FOR FILLING OUT FORMS: 1. FILL OUT IN INK. 2. Complete all forms. 3. Make sure all forms are SIGNED. 4. Make sure all forms, copies, and/or faxes are legible
SUNY ADIRONDACK Sports Medicine Team & Athletic Training TABLE OF CONTENTS SUNY ADIRONDACK SPORTSMEDICINE TEAM MISSION CERTIFlED ATHLETIC TRAINER (ATC) SUNY ADIRONDACK ATHLETIC TRAINING INTRODUCTION STATEMENT
SOUTHEASTERN OKLAHOMA STATE UNIVERSITY ALCOHOL, TOBACCO, and OTHER DRUG-EDUCATION GUIDELINES and the DRUG-TESTING PROGRAM for STUDENT-ATHLETES Student-athletes are responsible for anything they ingest.
The College of Idaho Department of Intercollegiate Athletics Substance Abuse Policy The College of Idaho recognizes abuse and misuse occurs on a large scale in society today. The continuing rises in the
Sports Medicine Policy and Procedures A. Introduction DEPARTMENT OF INTERCOLLEGIATE ATHLETICS Lourdes University Athletic Department strives to provide the highest quality of health care to each and every
DEPARTMENT OF INTERCOLLEGIATE ATHLETICS SUBSTANCE ABUSE POLICY A. PURPOSE The Louisiana Tech University Athletic Department ( LA Tech ) has established the Athletic Department Assistance Program ( ADAP
Valdosta State University Department of Intercollegiate Athletics Alcohol, Substance Abuse and Drug Screening/Testing Policies and Procedures I. Introduction: The Department of Intercollegiate Athletics
MISSOURI VALLEY COLLEGE SPORTS MEDICINE POLICY AND PROCEDURE Athletes Name: Sport: Please review all of the forms in this packet. Each of the forms contains information important to the student athlete.
2014-15 Point Park University Medical Packet Enclosed you will find many of the necessary forms needed to compete in intercollegiate athletics during the 2014-15 year. Please return all completed forms
UNIVERSITY OF ILLINOIS AT URBANA-CHAMPAIGN DIVISION OF INTERCOLLEGIATE ATHLETICS STUDENT-ATHLETE ALCOHOL AND DRUG EDUCATION AND DRUG TESTING PROGRAM A. Overview The Division of Intercollegiate Athletics
LIBERTY UNIVERSITY CLUB SPORTS Health Insurance Information / Authorization s Name Classification: Date of Birth Sport Returning Athlete? Yes/No Social Security No. LU Email Permanent Home Address City/State/Zip
THOMPSON SCHOOL DISTRICT CHECKLIST FOR ATHLETIC PARTICIPATION Check as completed Part A - PARENT PERMIT FOR ATHLETIC PARTICIPATION AND INSURANCE COVERAGE Read and complete with parent or guardian. Release
University of West Florida Dear Argonaut, On behalf of the UWF Staff, I would like to welcome you to UWF and congratulate you on joining the UWF Athletic Department. I would like to take this time to inform
UNLV DEPARTMENT OF INTERCOLLEGIATE ATHLETICS DRUG PREVENTION, EDUCATION, TESTING AND TREATMENT PROGRAM Effective November 3, 1986 Revised May 1, 1990 Amended and revised May 29, 1993 Amended and revised
Western State Colorado University Department of Intercollegiate Athletics Policies, Procedures and Plans (3P) Manual Section: Student-Athlete Welfare - Drug Education and Drug Testing Program Last revised
Christian Brothers University Medical Care and Insurance Procedures (Revised 12/8/14) Medical Certification for individual Student Athlete Participation: Christian Brothers University requires all student-athletes
Baseball 2015 DATES June 22-24 Spartan Kids Day Camps Ages 6-12 years old Spartan Camp Ages 13-18 years old Directed by Head Coach Jake Boss and his coaching staff, along with current and former Spartans.
TEACHING STAFF EBERS PHYSICAL EXAINATION R 3160/Page 1 of 6 A. Definitions R 3160 PHYSICAL EXAINATION 1. Employee assurance statement means a statement signed by the employee certifying that information
UCF Athletics Association, Inc.,( UCFAA, Inc. ) recognizes that the use of certain drugs, legal or illegal, is not in the best interests of the student athlete or the UCFAA, Inc. It is the policy of the
POLICY TO ADDRESS SUSPECTED SPORTS RELATED HEAD INJURY/CONCUSSION The Easton Public Schools has adopted this policy to address the identification and proper handling of suspected head injury for students
HEAD INJURIES & CONCUSSION PREVENTION AND MANAGEMENT PROTOCOL Policy Statement In order to effectively and consistently manage head injuries, the Brooke Charter School has established the following protocol
NCAA CATASTROPHIC INJURY INSURANCE PROGRAM FREQUENTLY ASKED QUESTIONS APPLICABLE TO 8/1/12 TO 7/31/13 POLICY PERIOD This document is a summary of the NCAA Catastrophic Injury Insurance Program. The insurance
Acknowledgement of Receipt of Notice of Privacy Practices **You May Refuse to Sign This Acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. Signature For Office Use
Lamar County Board of Education Drug and Alcohol Program Procedures JSA I. General Policy Practical experience and research has proven that even small quantities of narcotics, abused prescription drugs
Hanleigh Management Inc. 50 Tice Blvd., Suite 122, Woodcliff Lake, New Jersey 07677 Phone: (201) 505-1050 or (800) 443-2922 / Facsimile: (201) 505-1051 www.hanleighinsurance.com MOTORSPORT PERSONAL ACCIDENT
1 UNIVERSITY OF TOLEDO SPORTS MEDICINE POLICIES AND PROCEDURES 1. Athletic Insurance Coverage. Revised 2009 Insurance coverage for any injury sustained while participating in an intercollegiate sport at
Sports Medicine Policies & Procedures The Sports medicine department is organized to provide high quality medical care to all student-athletes within intercollegiate athletic program. The health and well-being
TARLETON SPORTS MEDICINE Student-Athlete Medical Information TARLETON STATE UNIVERSITY ATHLETICS DEPARTMENT Box T-0080 Stephenville, TX 76402 254-968-9178 254-968-9674 FAX www.tarletonsports.com Dear Parent
Sports Medicine CONCUSSION CHECKLIST FOR COACHES 1. Read through the material included in the Concussion Packet for Coaches 2. Know the signs and symptoms of a concussion 3. Send the following forms home
#1 Texas Longhorn Boys Basketball Camp Fax: 512-471-4160 ATTN: Leslie Parks P.O. Box 7399 Austin, Texas 78713-7399 UNIVERSITY SPONSORED SUMMER SPORTS CAMPS M E M O R A N D U M DATE: TO: FROM: RE: Prospective
Mail completed form to: Marlin Health Services 1584 Wesleyan Drive FORM A Norfolk, VA 23504 Phone: (757) 455-3108 Health History immunization & Physical Form Virginia State law (code 23-7.5) requires all
Workman s Compensation Name: Sex: Phone Number: Age: Address (Street/City/State/Zip) Name of Employer: Phone: Address of Employer (Street/City/State/Zip) Date and time of accident?: Where were you taken
Policies of the University of North Texas 18.4.11 Intercollegiate Athletics Drug Education, Testing and Counseling Program Chapter 7 Student Affairs Policy Statement. The Administration of the University
PAYMENT AGREEMENT: We accept most insurance plans as a courtesy. We encourage you to familiarize yourself with your individual plan. Insurance coverage is an agreement between patient and insurance company
STUDENT-ATHLETE DRUG EDUCATION, PREVENTION, REHABILITATION AND SCREENING Neumann University seeks to provide an education that balances the liberal arts with the professions in an environment which promotes
Your consent to our cookies if you continue to use this website.