1 Athletic Training MEMO: Athletic Participation TO: DATE: FROM: All Varsity Student-Athletes and Parents For the Academic Year Michael DeSavage, Head Athletic Trainer NEW Athletes & TRANSFERS Welcome Pre-Participation Examination Forms: Per the NCAA, student-athletes who are beginning their initial season of eligibility shall be required to undergo a medical examination or evaluation administered or supervised by [the appropriate medical professional] The examination or evaluation must be administered within six months prior to participation in any practice, competition or out-of-season conditioning activities. *(The physical is good for one year and will expire on that date annually. Returning student-athletes must have a physical conducted annually in order to participate) Can also be found at: -There are 4 components: 1. The Information and Medical History Form 2. The Pre-participation Physical (Conducted by the appropriate medical professional: MD, DO, NP, or PA) 3. The Insurance Acknowledgement Form 4. Copy of the front and back of your insurance card (Unless you have School Insurance or military insurance). Mail or Fax to: WPI ATTN: Michael DeSavage FAX#: Athletic Training Department AND/OR 100 Institute Road ATTN: Michael DeSavage Worcester MA, Due Date - Fall Sports: August 1 st, Winter Sports: August 1 st, Spring Sports, August 1 st. - The packet in its entirety needs to be received prior to the start of your season. EARLIER THE BETTER. If you have any questions regarding this information please contact: Mike DeSavage at office# or Thank you for your cooperation.
2 Information and Medical History Form Office Use: CLEAR Athletic Training Sport: Last, First Name, MI: DATE OF EXAM: Year of graduation: DOB: / / SOC#: / / Home Address: Emergency contact number: E Contact Name: Athletes School/cell Phone# Address: Primary Care Physician Phone# Primary Medical Insurance: Policy Holder: Insurance Phone# Policy Number: MEDICAL HISTORY: Do you have any allergies to drugs, foods, insects etc.? Do you suffer from asthma? Are you currently taking any medications/supplements? Have you ever received a concussion? If yes, What severity and how many? Have you ever injured your neck or spine? Explain: Have you ever been hospitalized or under gone surgery of any type? (Include dates) Do you have a history of joint or muscle injuries? If yes, please explain? Have you ever broken a bone? If yes in the last 5 years, describe and give dates. Have you ever suffered from heat exhaustion or heat stroke? Have you ever had chest pain, shortness of breath or fatigue while exercising? Have you ever been diagnosed with a heart murmur or high blood pressure? Do you have any other health issues that would place you at risk of serious injury while participating in sports? Acceptance of Risk : WPI, in compliance with NCAA guidelines, reminds its student-athletes of the inherent risks of injury during intercollegiate athletic participation. WPI, and its athletic administrators, coaches, and sports medicine staff, shares these risks by endeavoring to create a safe environment for competition. For their part, student-athletes are strongly advised to adhere to their coaches', athletic trainers', and associated physicians' health and safety instructions, including the rules of their sport, while participating in contests, practices, training sessions, and travel to effectively reduce the risks of injury. Athletes please read and sign below. Minors require parental signature. Consent for treatment: I hereby give consent to the WPI Athletic Training staff and affiliates for routine medical treatment of minor injuries or illnesses and in the event of an emergency permission to secure appropriate treatment for me including orders for emergency surgery and anesthesia if necessary. Consent to Release: My signature below verifies the release of relevant medical information to the WPI Athletic Training Staff and affiliates to include the team physician s office and WPI Health Services. (This release may be rescinded upon request). Student signature Signature of parent or guardian Printed name of parent or guardian
3 Athletic Training Pre-Participation Physical Form Athletic Training Department 100 Institute Road Worcester, MA Date of exam: Name: Sport: HEIGHT: in. WEIGHT: lbs. BP: PULSE: RESPIRATIONS: ALLERGIES: NORMAL NO. SYSTEM Yes No List number of deformities and describe 1. Skin 2. Eyes 3. Ears 4. Nose & throat 5. Lymphatics 6. Chest & lungs 7. Acne 8. Abdomen 9. Hernia 10. Genitalia 11. Pelvic 12. Rectal 13. Orthopedics 14. Neurological 15. Psychological 16. Cardiology Exam should include: * Precordial ausculations (supine and standing) to identify murmurs, specifically related to the left ventrical out flow obstruction. Normal Abnormal Explain: * Assess femoral artery pulses to rule out coactation. Normal Abnormal Explain below * Assess for physical stigmata of Marfans Syndrome. Normal Abnormal Explain below * Assess brachial artery blood pressure while sitting. Normal Abnormal Explain below 17. I have known the applicant for years. 18. The applicant is in: Excellent Good Poor Health. 19. YES NO THE APPLICANT MAY PARTICIPATE IN SPORTS WITHOUT RESTRICTION Do you have any recommendations for the care of this student? No Yes Explain: The following abnormalities should be noted. The applicant: Has a loss of or seriously impaired function of an organ. Yes No Should not participate in sports due to:, M.D. Print name of physician Physician Office Stamp Signature Explanations:
4 INSURANCE REQUIREMENT ACKNOWLEDGEMENT For Academic Year Department of Physical Education, Recreation & Athletics SUBJECT: TO: FROM: Varsity Student-Athlete Insurance WPI Student-Athletes and Parents Dana L. Harmon, Director of Athletics Please note per the NCAA, all student-athletes must provide evidence of insurance that includes coverage for athletically-related injuries. This is a pre-requisite for practice and competition. No student will be allowed to participate in any way until such evidence of current insurance coverage is on file with the WPI Department of Athletics. The enclosed Insurance Requirement Acknowledgement Form, a completed Information and Medical History Form, a completed Pre-Participation Exam (physical) Form and a photocopy of both sides of your current insurance card must be on file before a student can participate. Your insurance coverage should have a limit of at least $75,000 and cover athletically-related injuries (no exclusions). If you have questions regarding the terms of your coverage, you should contact your insurer immediately. If your insurance does not cover athletically related injuries, you must purchase WPI s student insurance for your son or daughter to participate. Information can be found at search term: student health insurance. If your insurance does cover athletically related injuries but has exclusions and/or is less than $75,000 in coverage, please be aware that you are responsible for any and all expenses up to $75,000 unless you purchase additional coverage on your own or through WPI s student insurance. WPI will assume no responsibility whatsoever for the payment of, or authorization to pay, medical or dental expenses resulting from injuries that occur while participating in intercollegiate athletics at WPI. For your information, the NCAA s Catastrophic Injury Insurance Program covers student-athletes who are catastrophically injured while participating in a covered intercollegiate athletic activity (subject to all policy terms and conditions). The policy has a $75,000 deductible. This coverage does not qualify as the basic coverage required for participation in athletics at WPI. It is supplemental coverage in the event of a catastrophic injury. More information on this program can be found on the NCAA's web-site at If you have any questions regarding this requirement, please contact Mike DeSavage at This form does not need to be returned. It is provided for your information.
5 This form must be signed by a parent, guardian, legal representative or policy holder Acceptance of Risk: WPI, in compliance with NCAA guidelines, reminds its student-athletes of the inherent risks of injury during intercollegiate athletic participation. WPI, and its athletic administrators, coaches, and sports medicine staff, shares these risks by endeavoring to create a safe environment for competition. For their part, student -athletes are strongly advised to adhere to their coaches', athletic trainers', and associated physicians' health and safety instructions, including the rules of their sport, while participating in contests, practices, training sessions, and travel to effectively reduce the risks of injury. INSURANCE REQUIREMENT ACKNOWLEDGEMENT I,, as parent, guardian or legal representative, attest that (name, please print) has insurance coverage under a current, in force insurance (student-athlete name) policy or policies for injuries that occur while he/she is participating in intercollegiate athletics. I am aware that this coverage should be at least $75,000 and that I am responsible for any and all expenses up to $75,000. If there is a material change in coverage or expiration of coverage, I agree to notify WPI of this development and update the insurance information I have on file with the WPI Athletic Department. I understand and agree that WPI will assume no responsibility whatsoever for the payment of, or authorization to pay, medical expenses resulting in injuries that occur while participating in intercollegiate athletics at WPI. (parent, guardian or legal representative signature) (date) The following need to be returned to the Athletic Training Office in order to be considered for participation: 1) THIS INSURANCE ACKNOWLEDGEMENT FORM, SIGNED (BY PARENT, GAURDIAN OR LEGAL REPRESENATIVE) 2) COMPLETED AND SIGNED INFORMATION AND MEDICAL HISTORY FORM 3) COMPLETED PRE-PARTICIPATION PHYSICAL FORM WITH BOX 19 CHECKED OFF 4) COPY (FRONT AND BACK) OF YOUR CURRENT INSURANCE CARD
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
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
Yevgeniy Khavkin, MD Center for Spine and Brain Health 653 N Town Center Dr Ste 308 Las Vegas, NV 89144 (702)242-3223 Fax (702)673-1155 Dear, Welcome to our practice. Your visit is with Yevgeniy Kkavkin,
#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
Print, Complete and Return This Form MEDICAL FORMS PACKET PLEASE RETURN ALL FORMS THAT STATE SIGN AND RETURN ALONG WITH THIS PAGE TO THE FOLLOWING ADDRESS. BE SURE TO INCLUDE THE NAME OF THE CAMP IN THE
Worker s Compensation Intake Form Patient Information: Name Home Phone Address Work Phone Social Security No. Date of Birth Sex Male Female Height Weight lbs Occupation Marital Status Employer No of Children
Life Insurance Application Application To: United of Omaha Life Insurance Company ATTN: Life Agency: Mutual of Omaha Plaza, Omaha, NE 68175 ATTN: Life Brokerage: P.O. Box 2476, Omaha, NE 68103-2476 For
Medical management of sports-related concussion continues to evolve. Recently, there has been a significant amount of new research regarding sports-related concussions in high school athletes, including
Personal Injury Intake Form Patient Information: Name Home Phone Address Work Phone Cell Phone Date of Birth Social Security # Sex Male Female Height Weight lbs Occupation Marital Status Employer No of
BAYWEST HEALTH & REHAB Managed Care / Medicare NPR Date Patient Name: How did you hear about us? Sex: M F Marital Status: Married Divorced Single Widowed DOB: Patient Social Security #: Driver s License
Medicare Patient Information Patient Name: SS#: - - Date of Birth: / / Sex: Female Male Address: Street: City: State: Zip Code: Home Phone: ( ) - Work/Mobile Phone: ( ) - Please print your name as it Appears
Disability Income Insurance for New York State Physicians The coverage that works for you when you can t work. Administered by: Charles J. Sellers & Company, Inc. Underwritten by: Protect Your Family's
New Patient Registration Information ADAMS COUNTY LOCATIONS YORK COUNTY LOCATIONS Adams Health Center........ (717) 339-2620 Apple Hill................ (717) 741-8240 Aspers Health Center........ (717)
Today s Date: / / / / Full Legal Name (First, Middle, Last) Date of Birth Age Social Security Number Marital Status Address City State Zip Out of State Address Phone: Home ( ) - Cell ( ) - Email: PREFERRED
HOWARD J. GELB, M.D., F.A.A.O.S. Board Certified Orthopaedic Surgeon Fellowship Trained in Sports Medicine Sub-specialty Certified in Sports Medicine CLIVE C. WOODS, MD Orthopaedic Surgeon Fellowship Trained
A) PATIENT INTAKE/TREATMENT FORM 1) Patient Name: 2) Social Security #: 3) Home Phone number: ( ), Cell: ( ), Work: ( ) 4) Address: City, State, Zip Code 5) Gender: M F 6) Date of Birth (DOB): / / 7) Marital
Welcome to the Rehabilitation Center of Southern Maryland. Thank you for giving us the opportunity to care for your Physical/Occupational therapy needs. We look forward to helping you in every way we can.
Patient Information DEMOGRAPHICS Joint Effort Rehab, LLC First Name: MI: Last Name: Sex: M F Home Phone: Work Phone: Cell Phone: SSN: of Birth: Email: Referring Physician: Employer Name: Primary Insurance
2014-2015 Policies and Procedures Manual TABLE OF CONTENTS Sports Medicine Team...2 Medical Documentation and Physicals...4 Prescription and Over the Counter Medication Management...10 ADD/ADHD Medication...13
Welcome to VibrantCare Rehabilitation Thank you for choosing VibrantCare Rehabilitation. We know you and your physician have a choice in your therapy provider and we are pleased you have chosen us. Please
Better Care For Better Living Thank you for choosing Direct RehabMed for your healthcare needs. The following pages include our new patient registration paperwork that is required for your visit. We would
The Richwood School-Based Health Center is pleased to offer medical, mental health counseling, health education, and on site dental services to all Richwood Middle School and Richwood High School students.
MALINA CHIROPRACTIC 3826 N. Druid Hills Rd Decatur Georgia 30033 Office 404-352-3609 Fax 404-325-8859 Car Accident Questionnaire Name: Age: Date of birth: Date: LAST FIRST MIDDLE Address: Social Security
Date: OAHU SPINE & REHAB Patient Information Form Pt. Number: First Name Last Name Date of Birth / / Address City State Zip Home Ph ( ) Work Ph ( ) Age Email Social Security # - - Sex: M / F Driver s License
Flyer Registration Form Name: Mailing Address: City: State: Zip: Country: Home Phone: Mobile Phone: Email Address: Date of proposed flight: Have you previously flown parabolic flight? If yes, when, where,
The University of Arizona 2013-2014 Cheerleading Tryouts INFORMATION PACKET Check List Timeline General Information (Mission, Skills, Commitment, and Benefits) Evaluation Details Sample Score Sheets Application