LEES-MCRAE COLLEGE HISTORY FOR ANNUAL CHECK-UP. TODAYS DATE:, 20 Sport:

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1 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 Page 3 MUST be completed by the physician or health professional that performs the physical examination Once forms are completed return to: Lees-McRae College Athletic Training PO Box 128 Banner Elk, NC TODAYS DATE:, 20 Sport: LAST NAME: FIRST NAME: MI: HOME ADDRESS: CITY: STATE: ZIP: HOME PHONE: ( ) - ATHLETE S CELL #: ( ) - BIRTHDATE: / / SOCIAL SECURITY NUMBER - - GENDER: FEMALE MALE YEAR IN SCHOOL: FR. SOPH. JR. SR. In case of emergency, Contact: Name: Phone: ( ) - Relationship: Cell #: ( ) - Have you ever had (write YES or NO); if YES give approximate date or age at time Asthma: Scarlet Fever: Hay Fever Diphtheria Hives Diabetes Anemia Peptic Ulcer Kidney Disease Heart Disease Thyroid Disease Rheumatic Fever Tuberculosis Hernia Bronchitis Skin Rash Mononucleosis Kidney Problems Concussions Headaches Dizziness Convulsions High Blood Pressure Neck Injury Sickle Cell Sickle Cell Trait (Must have Documentation) Blood in Sputum Blood in Stool Blood in Vomitus Blood in Urine Chronic Disease of: Eyes Ears Nose Throat Stomach

2 For Women: 1. At what age did you experience your first menstrual period? 2. In the last year, what was the longest time you have gone between periods? 3. Do you have any difficulties with your period (e.g., painful cramping)? For men & women: List any other Illnesses: Do you wear: Glasses Contacts Current Medication(s) you are taking: Allergies: Medicine Allergies: of last Tetanus Shot: List any injuries that required you to see a Dr., stay in hospital, miss practice or game (give approximate date): List any operations, surgeries (give approximate dates): List any surgeries that were recommended but not performed: List any current medical problems: I hereby state that, to the best of my knowledge, my answers to the above questions are correct. Athlete s Signature For Parents/guardians of student-athletes under the age of 18 I hereby authorize any medical treatment for my son/daughter, which may be advised or recommended by the medical staff, Athletic Training and Health Services, at Lees-McRae College. Signature of parent/guardian

3 LEES-MCRAE COLLEGE ATHLETICS PHYSICAL EXAMINATION NAME: Today s DATE:, 20 of Birth: MEDICATIONS: ALLERGIES: INTERVAL HISTORY: FAMILY HISTORY: CURRENT SYMPTOMS: ROS: PHYSICAL EXAMINATION: HEIGHT- WEIGHT- B P PULSE- NORMAL ABNORMAL EXPLAINATION EYES SKIN NODES HEENT LUNGS HEART ABDOMEN HERNIA GENITALIA ORTHOPEDIC EXTREMITIES SPINE CNS Per NCAA Guidelines, All Lees-McRae College student athletes MUST show proof of Sickle Cell Testing & Trait Status via a copy of the results! Sickle Cell Positive? YES NO Sickle Cell Trait Yes NO LABORATORY (at physician s discretion): URINALYSIS: Blood: DIAGNOSIS: RECOMMENDATION FOR PHYSICAL ACTIVITY Reason: UNLIMITED: LIMITED: PHYSICIAN SIGNATURE & DATE PRINT NAME OF PHYSICIAN PHONE #

4 SICKLE CELL TESTING REQUIREMENT ALL Lees-McRae Student Athletes for MUST show proof of SICKLE CELL TRAIT TESTING The NCAA requires that all student athletes have Sickle Cell Trait Testing. This requirement was adopted by the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports. The NCAA recommendation follows the latest guidelines from the National Athletic Trainers Association (NATA) and the College of American Pathologists (CAPS). Both the NATA and CAPS recommend screening for the Sickle Cell Trait if a student athlete s status in not known. In the United States, Sickle Cell Disease is predominant in those of African, Mediterranean, Middle Eastern, Carribean, and Indian ancestry. It also affects other groups including Hispanics/ Latinos and Asians. A growing number of Caucasian Americans in North Carolina are being identified with Sickle Cell trait (carrier) and other abnormal hemoglobin types. Sickle Cell Disease is a group of inherited red blood cell disorders. Normally, red blood cells are soft, round and smooth. Their round shape allows them to carry a sufficient amount of oxygen and move easily throughout the body. With Sickle Cell Disease, red blood cells can become hard, sticky and shaped like crescents (or sickles). Sickling of the red blood cells affects circulation and reduces the amount of oxygen carried to the body s cells and tissues. It causes symptoms ranging from pain, to organ damage, to anemia, infection and even strokes. Also, it can lead to a life threatening condition known as rhabdomyolysis that occurs with athletic activity and exercise. Rhabdomyolysis is the breakdown of muscle fibers resulting in the release of muscle fiber contents (myoglobin) into the bloodstream. This is very harmful to the kidneys and frequently results in kidney damage. Having the Sickle Cell Trait does not preclude participation in varsity athletics but does permit adjustment in the training regimen for athletic activity and helps facilitate treatment as needed. Recommendations: 1. Check with your local health department. You may have been tested at birth & if so they may have this record. 2. Have the test included when you have you physical. NO STUDENT ATHLETE WILL BE ALLOWED TO PRACTICE OR PLAY WITHOUT PROOF OF THIS TEST! (copy of the actual test results) Returning student athletes do not have to resubmit. The information is on file.

5 TO: FROM: Parents of Lees-McRae College Intercollegiate Athletes Jeanette Burleson, Student Accounts Manager THE ENCLOSED FORMS MUST BE COMPLETED AND RETURNED TO THE LEES-MCRAE COLLEGE BUSINESS OFFICE BEFORE YOUR SON/DAUGHTER WILL BE PERMITTED TO ENGAGE IN ATHLETIC PRACTICE OR COMPETITION. Lees-McRae College wishes to assure you that our qualified and trained athletic staff will do everything possible to keep your son or daughter free from injuries while participating in our intercollegiate program. We have also made every effort to provide the best medical care available with minimum confusion and cost if any injury to our athletes should occur. To accomplish this important task, we need your help. PLEASE READ THIS LETTER CAREFULLY. If any medical or operative procedure ever becomes necessary, every attempt will be made to contact you prior to the institution of any therapy; however, on rare occasions it is necessary to proceed in an emergency situation before you, the parents, can be reached. Should this occur, we must have a signed authorization allowing us to do so and the enclosed form will permit us to render the emergency care you would rightfully expect of us. Please fill in the name and relationship of the parent or guardian and have that person sign the form. Lees-McRae College has purchased an accident insurance policy for intercollegiate sports participants. The first $500 of reasonable and customary charges of accidental injury will be paid in full. Any claim exceeding $500 to $75,000 will be paid only after any other group or individual medical plan has paid primary coverage on the claim. Benefits for dental treatment due to injury to sound natural teeth are limited to $200 per tooth. The plan also has a $5,000 Life/Accidental Death and Dismemberment Benefit. Any claim exceeding the first $500 of reasonable and customary charges must be filed with your insurance carrier. You will receive a claims summary statement from your carrier showing how much they paid on the claim. Please mail a copy of this summary to Murray White Associates, Inc., P.O. Box 2196, High Point, N.C After receipt of this summary, Guaranty Trust Life Insurance Company will pay any excess charges not paid by your insurance company to the limits of the policy. Please note If the primary family coverage is through an HMO (Health Maintenance Organization) or PPO (Preferred Provider Organization) you must follow the proper procedures required by your plan in order for the college s insurance to satisfactorily complete its portion of the claim. This is especially important if your plan requires pre-authorization to have your son/daughter treated if out of your plan s service area. Each student is required to have a physical examination by a licensed physician prior to any participation in any intercollegiate sport. The final decision on physical qualifications is the responsibility of the physician and the Lees-McRae College Certified Athletic Trainers. Please be aware that the athletic policy only covers accidental injury connected with intercollegiate sports. Nonathletic injuries are excluded. It does not cover sickness. The accident must occur during supervised play, practice or group team travel to or from scheduled intercollegiate athletic events. Occurrences that are not injuries or do not occur during supervised practices or scheduled intercollegiate sports are not the responsibility of Lees-McRae College. With the above in mind, please retain this letter for future reference and within one week return the enclosed form to me. All student athletes initial or continued participation in our sports program is dependent on the prompt return of these forms. Thank you for your cooperation and should you have any inquiries, please contact Murray White Associates, Inc., P.O. Box 2196, High Point, N.C or phone (336) or toll free Enclosure

6 Lees-McRae College Parent Information Form Parents/Guardian to complete and return to: Lees-McRae College Athletic Training PO Box 128 Banner Elk, NC PLEASE ATTACH A COPY OF THE FRONT AND BACK OF PERSONAL INSURANCE CARD. Failure to complete all blanks will result in claims processing delays. 1. Name of Student: Sport: Social Security #: of Birth: College Phone: Home Phone: City: State: Zip: 2. Father/Guardian: Mother/Guardian: Social Security #: Social Security #: 3. Employer: Employer: Telephone: Telephone: 4. Medical Insurance: Medical Insurance: *(If coverage extends to student) *(If coverage extends to student) Company or Plan: Company or Plan: Policy Number: Policy Number: Telephone: Telephone: Is the company or plan listed above considered a Health Maintenance Organization (HMO)? Yes No or a Preferred Provider Organization (PPO)? Yes No Is pre-authorization required to obtain treatment? Yes No Does your insurance or plan require a second opinion before surgery? Yes No I hereby authorize Lees-McRae College and First Agency of Kalamazoo, Michigan to inspect or secure copies of case history records, laboratory reports, diagnoses, x-rays, and any other data covering this and/or previous confinements and/or disabilities. A photostatic copy of this authorization shall be deemed as effective and valid as the original. We authorize that the college or its insurance agent pay the medical vendors direct for any bills incurred from accidents that are covered under the coverage purchased through the college. Parent s Signature: Student s Signature:

7 Lees-McRae College Authorization for Disclosure of Health & Claims Information Member Name: (Student Athlete) Member Social Security Number: of Birth: As described below, I hereby voluntarily authorize Murray White Associates, Inc. and Lees- McRae College and their affiliates, including the Athletic Training Program, to obtain my individually identifiable health information and that of my covered dependents. I understand the information will be disclosed only to the person(s) organization(s) I list below, for the purpose of administering insurance benefits, unless otherwise permitted by law: Agency Name: Murray White Associates, Inc. College Contact Name: Carolyn Ward &/or Jeanette Burleson Legal Representative Name: Other (Name and relationship to the member): I understand that the information I have authorized to be disclosed may include confidential personal claims administration information about me or my covered dependents. I understand that I may revoke this authorization at any time by notifying the provider in writing. I also understand that upon the processing of this authorization by member, all previous authorizations signed by me are automatically revoked but that a revocation will not have any effect on the actions taken by the provider before the revocation is processed. Signature of Member or Legal Representative My facsimile signature is as valid as if it were an original. Parents/Guardian to complete and return to: Lees-McRae College Athletic Training PO Box 128 Banner Elk, NC

8 Lees-McRae College MEDICAL AUTHORIZATION FORM This form is to be completed by parents or guardians of Lees-McRae College students participating in the intercollegiate sports program. Equipment issue to student athletes will be delayed until this form is received in the Business Office!! Athlete s Last Name First Name MI Permission is hereby granted to any medical provider to proceed with any needed medical or minor treatment, x-ray examination, and immunization for the above named student athlete. In the event of serious illness, the need for major surgery or significant accidental injury, I understand that an attempt will be made by the attending physician to contact me in the most expeditious manner possible. If said physician is unable to communicate with me, the treatment necessary for the best interest of the above named student may be given. I acknowledge receiving the Athlete Injury Insurance Letter. I understand the extent of the college s responsibility to an athlete who becomes injured as a result of participation in the intercollegiate sports program at Lees-McRae College. I also understand there is an assumed risk involved in intercollegiate athletics. I, hereby, authorize Lees-McRae College and/or its medical vendors to make direct claims for bills incurred to the above named insurance carrier for the above named student athlete. Signature Relationship to Student Athlete Complete and return to: Lees-McRae College Athletic Training PO Box 128 Banner Elk, NC