ATTENTION STUDENT-ATHLETE PARENT/GUARDIAN

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1 ATTENTION STUDENT-ATHLETE PARENT/GUARDIAN All first-year and transfer students have two SEPARATE requirements: Requirement #1 is for ADMISSION to Shippensburg University (see checklist below). Requirement #2 is for PARTICIPATION IN A SPORT as a student. A physical will be administered when the student-athlete arrives on campus through the Department of Sports Medicine (see checklist on next page). All returning student-athletes must complete this requirement. MEDICAL FORMS FOR REQUIREMENT #1 (TO ATTEND COLLEGE) Below is a checklist of the forms that must be completed for ETTER HEALTH CENTER prior to arrival and admission to Shippensburg University. Please carefully read the information below. These forms are separate & in addition to the required Sports Medicine forms needed! FORMS FOR FIRST-YEAR AND TRANSFERS: Shippensburg University Student Health Record Immunizations (must include dates of state required immunizations) Meningitis Vaccine (complete online) Forms can be downloaded at the following link: The Student Health Record, Immunizations and Meningitis Vaccine forms are REQUIRED for admission to SHIPPENSBURG UNIVERSITY. The Student Health Record and Immunizations must be mailed and received by AUGUST 1, 2015 to: ETTER HEALTH CENTER Shippensburg University 1871 Old Main Drive Shippensburg, PA The Meningitis Vaccine form must be completed online. For questions, please call Etter Health Center at (717)

2 Shippensburg University Department of Sports Medicine MEDICAL FORMS FOR REQUIREMENT #2 (TO PARTICIPATE IN A SPORT) Please read all information and instructions prior to completing the forms for the Department of Sports Medicine. Please complete and return all of the forms following the instructions on the next page. Copy of Sickle Cell Trait Testing Results (first-year and transfers only) or Sickle Cell Trait Testing Waiver Form (first-year and transfers only) Concussion Acknowledgement Form Insurance Information Form Copy of Insurance Card (front and back) Medical Examination and Authorization Form Health Checklist Health History Forms (2 pages) Orthopedic History Form ADHD Documentation ***only if applicable*** All student-athletes will receive a mandatory on-campus pre-participation physical through the Department of Sports Medicine for authorization to participate in any practice or competition.

3 Instructions IMPORTANT: Please print all forms single-sided for our record-keeping purposes DO NOT print double-sided, use a pen and print clearly. Prior to your participation the Department of Sports Medicine requires a few medical forms to be completed before your arrival on campus. To ensure that there is no delay in your participation, please follow these instructions very carefully. All first-year and transfers are required to have a completed student health record, completed Meningitis Vaccine form and current immunization records on file at Etter Health Center for admission to SU. Questions may be referred to Etter Health Center at (717) In addition, all student-athletes will receive a mandatory on-campus pre-participation physical through the Department of Sports Medicine for authorization to participate in any practice or competition (as explained on the previous page). FIRST-YEAR/TRANSFER STUDENT-ATHLETES & RETURNING STUDENT-ATHLETES WITH ADHD PRESCRIPTION CHANGES MUST READ THE ENCLOSED ATTACHMENT REGARDING ATTENTION DEFICIT HYPERACTIVITY DISORDER 1. FOR FIRST-YEAR AND TRANSFERS ONLY Sickle Cell Trait Testing Results OR Waiver Form: You have 2 options: (a) Provide a copy of your Sickle Cell Trait Test Results; OR (b) Complete the Sickle Cell Trait Waiver Form. Please read carefully and sign the bottom of the form. If you are younger than 18 years old, your parents/guardians must also sign and date the form. 2. Concussion Acknowledgement Form: Please read carefully and sign the bottom of the form. If you are younger than 18 years old, your parents/guardians must also sign and date the form. 3. Insurance Information Form: Have your parents complete the relevant information. You must sign the bottom of this form. In addition: PLEASE MAKE A COPY OF YOUR INSURANCE CARD, FRONT AND BACK, AND ENCLOSE IT WITH THE INSURANCE INFORMATION FORM. You cannot receive a pre-participation physical without the completion of this form and you must have a copy of your insurance card enclosed. If you are younger than 18 years old, your parents/guardians must also sign and date the form. 4. Medical Examination and Authorization Form: Please read carefully and sign the bottom of the form. If you are younger than 18 years old, your parents/guardians must also sign and date the form. 5. Health Checklist Form: Please fill out COMPLETELY. 6. Health History Forms: Please check either no or yes for all questions. For yes answers please provide a brief description in the space provided. Be sure to sign both pages of this form. If you are younger than 18 years old, your parents/guardians must also sign and date both pages of the form. 7. Orthopedic History Form: Please check either no or yes for all questions. For yes answers please provide a brief description in the space provided. Be sure to sign the bottom of this form. If you are younger than 18 years old, your parents/guardians must also sign and date the bottom of the form.

4 8. Return All Forms: Please enclose the following completed items: Sickle Cell Trait Testing Results OR Sickle Cell Trait Testing Waiver Form (First-Year/Transfers Only) Concussion Acknowledgement Form Insurance Information Form (with copies of FRONT & BACK of insurance card) Medical Examination and Authorization Form Health Checklist Form Health History Forms (2 pages) Orthopedic History Form *ADHD If applicable, provide documentation listed in enclosed ADHD Guidelines ** Incomplete forms will delay your eligibility for a pre-participation physical **! All sports must have the forms postmarked by August 3. DO NOT FAX OR DOCUMENTS Faxed or ed documents will be rejected because ORIGINAL signatures are required! Also included are three documents explaining Shippensburg University s insurance policy. Please read these carefully. If you have any questions regarding the forms, please feel free to contact the Department of Sports Medicine at (717) , ext. 8 or Thank you for your time and we look forward to seeing you at the start of your season.

5 SUBJECT: INTERCOLLEGIATE ATHLETIC INSURANCE TO: FROM: The Parents/Guardians of Student-Athletes Mr. Jeffrey Michaels, Director of Athletics Every student-athlete is required to have primary medical insurance coverage to participate in intercollegiate athletics at Shippensburg University. The insurance policy MUST cover intercollegiate athletic injuries. Intercollegiate athletic insurance is provided as secondary coverage at no charge for any student certified eligible to participate in intercollegiate athletics/cheerleading at Shippensburg University. The policy only covers injuries sustained in official team activities such as: games, practices, weight training, conditioning, and travel. Coverage is limited to bills incurred within two years of the date of the accident. Shippensburg University, Shippensburg University Student Services, Inc., the Department of Athletics, and the Department of Sports Medicine will NOT be responsible for any medical bill received as the result of an athletic injury if the student-athlete does not have primary medical insurance. Government-funded insurance plans (such as Tricare) are NOT considered primary medical insurance. If a studentathlete has a government-funded insurance plan, the student-athlete must purchase another medical insurance plan. Consolidated Health Plans ( is the recommended insurer for student-athletes with a government-funded insurance plan. Other insurance plans are acceptable if they cover intercollegiate athletic injuries and are considered primary medical insurance. International student-athletes MUST have primary medical insurance that covers INTERCOLLEGIATE ATHLETIC INJURIES. The recommended insurance plan for international student-athletes is the Geo Blue Navigator 250 Plan. Other insurance plans are acceptable, if comparable to the Geo Blue Navigator 250 Plan. Any plan other than the Geo Blue Navigator 250 plan MUST be approved by the Department of Sports Medicine prior to participation. Information regarding the Geo Blue Navigator 250 insurance plan can be found at: Out of Season/Non-Athletic-Related Injury: Shippensburg University, Shippensburg University Student Services, Inc., the Department of Athletics, and the Department of Sports Medicine shall NOT assume responsibility for the care of any injury incurred when the student-athlete is not actively engaged in a formal, official, sanctioned practice or game during an NCAA allowable season. Questions in this area should be referred to the Director of Athletics or the Director of Sports Medicine. Parents/Guardians and student-athletes are encouraged to thoroughly examine the enclosed letter, which outlines the intercollegiate athletic insurance policies at Shippensburg University. Additionally, the procedures and responsibilities for students regarding athletic insurance, illnesses, and medical care are described in this letter. All bills incurred from athletic-related injuries should be sent to the student-athlete s parent s/guardian s insurance carrier. Only after the student-athlete s parent s/guardian s insurance carrier makes payment, partial payment, or rejects payment, does Shippensburg University s secondary athletic insurance policy make a payment on any balance due. All copies of itemized bills and explanation of benefit (E.O.B.) statements that you receive from your insurance carrier indicating payment, partial payment, or rejection of payment must be faxed or mailed to the address below to ensure complete payment of all bills. Shippensburg University will not be responsible for payment of any medical bills, if the above procedures are not followed.

6 Student-athletes covered under HMO insurance plans have special policies and procedures to follow prior to receiving medical services. Please make sure the Department of Sports Medicine is notified of these procedures on the attached form. EACH STUDENT-ATHLETE MUST HAVE THIS INSURANCE FORM AND A COPY (FRONT AND BACK) OF YOUR or HIS/HER INSURANCE CARD ON FILE WITH OUR SPORTS MEDICINE STAFF BEFORE HE/SHE WILL BE ELIGIBLE TO PARTICIPATE. If you have any questions or concerns not covered by the letter, please feel free to contact: Department of Sports Medicine Shippensburg University 1871 Old Main Drive Shippensburg, PA Telephone: (717) , ext. 8 Fax: (717)

7 This letter is a supplement in regards to the requirement of every student-athlete having primary medical insurance coverage to participate in intercollegiate athletics at Shippensburg University. To clarify this requirement additional information has been provided within this letter. Please make sure you are aware of any and all limitations of your primary medical coverage. Many managed care insurance company policies (HMO, PPO, POS, etc.) have limited coverage areas/networks, which will not permit medical services to be provided while at college. u Example: A student-athlete injures his/her knee and the injury requires a physician evaluation, x-ray and/ or other medical procedure. Many managed care providers will require the student-athlete to return home to see the primary care physician or a physician within the coverage area. This can delay treatment and become very frustrating for the student-athlete and you as the parent(s)/guardian(s). In addition, there is the burden of travel for appointments which may cause the student-athlete to miss considerable class time. Although, there is no simple solution to the above problem, I would like to provide some other additional information that you may want to consider, so that this situation may possibly be avoided. 1. Change your Primary Care Provider/Physician to a local physician in the Shippensburg, Chambersburg, and/or Carlisle area if they are a participant with your insurance. a. Baxter Drew Wellmon II, D.O. Family Practice 97 Progress Blvd., Suite 1 Shippensburg, PA (717) Ask your insurance company about out of area/network services for your son/daughter while away at college. 3. Please provide your insurance company with an updated student enrollment form. 4. Verify the age limitation for your son/daughter to remain on your health insurance policy. 5. If there is a loss of health insurance, inquire Reminder: Every student-athlete is required to have primary medical insurance coverage to participate in intercollegiate athletics at Shippensburg University. Please refer to the previous memo for eligibility requirements. Please contact the Department of Sports Medicine at (717) , ext. 8, or if you have any questions. Sincerely, Wesley R. Mallicone, MS, LAT, ATC Director of Sports Medicine

8 Department of Sports Medicine INTERCOLLEGIATE ATHLETIC ACCIDENT INSURANCE COVERAGE Please read carefully Athletic Accident Insurance is provided by Shippensburg University for the benefit of our student-athletes. This coverage is offered on a FULL EXCESS basis only. Under the terms of the policy, the coverage is considered the secondary payor to all valid and collectable medical insurance policies. Most notable would be parental/guardian insurance coverage through their place of employment under which the student-athlete is covered as an eligible dependent. Every student athlete must have primary medical insurance coverage in order to be eligible to participate in intercollegiate athletics at Shippensburg University. The Athletic Accident Insurance is comprehensive, but it has limitations. It does not cover expenses due to illness or non-athletic related injuries. It does not cover expenses incurred from Outside Medical Specialists unless pre-approved by the University s Team Physician and the Director of Sports Medicine. All surgical treatments must be approved in writing. Only those bills incurred within a period of two years from the date of the injury are covered. Catastrophic insurance is available through the NCAA and must be initiated within the same two year period. Therefore, each student-athlete must carry personal health insurance to cover such expenses should they arise. Failure of a student-athlete to carry personal health insurance may delay medical treatment, which will result in a suspension from competitive athletics. Shippensburg University, Shippensburg University Student Services, Inc., the Department of Athletics, and the Department of Sports Medicine will NOT be responsible for any medical bill received as the result of an athletic injury if the student-athlete does not have primary medical insurance. What does FULL EXCESS mean? This means that the injured student-athlete must first claim benefits under any other valid and collectable medical insurance policies. This would include Blue Cross/Blue Shield, any private accident and health, or HMO/PPO policies and/or group policies through you or your parent s/guardian s employer. If there are any balances that remain unpaid after payment has been made by your primary insurance carrier, you must then submit the primary insurance company s Explanation of Benefits (EOB) statement and the corresponding itemized billings to Shippensburg University s Department of Sports Medicine for benefit consideration on the outstanding balance due portion of the bills. A. If the student-athlete s additional coverage is exhausted, then Shippensburg University s Athletic Accident Benefit policy will take over and cover any necessary medical bills. It is required that the studentathlete or parent/guardian show proof of exhausted health and accident coverage. If the injured studentathlete s medical bills exceed the policy limits, which must be met within the two year period, then the NCAA catastrophic plan takes effect up to $20,000,000 for long term catastrophic injury. B. Coverage under the policy provides payment for the Usual, Customary and Reasonable (UCR) charge of necessary medical bills due to a Covered Accident and other medical conditions resulting from athletic participation incurred during a scheduled practice or game. Note: To be eligible for the NCAA Catastrophic plan, a claim must have reached the $90,000 limit within the 24 month period beginning from the date of the covered accident.

9 C. COVERAGE IS LIMITED TO BILLS INCURRED WITHIN TWO YEARS OF THE DATE OF THE ACCIDENT WITH THE FOLLOWING PROVISIONS: 1. A Covered Expense must be incurred as a direct result of a Covered Accident within a period of 180 days following a Covered Accident. D. Filing a Claim: For insurance coverage to take effect, certain minimal requirements are necessary. The Injured Student-Athlete MUST: 1. Sign and file an athletic accident claim form with the Department of Sports Medicine following the injury. 2. Submit to the Department of Sports Medicine, all bills and your insurance carriers corresponding explanation of benefits (EOB) statement for submission to Shippensburg University s athletic insurance carrier. It is the student-athlete s responsibility to secure all bills and payment receipts for submission. 3. Submit only those bills incurred within twenty-four (24) months of the date of the accident. Close inspection of the principles regarding payment of insurance bills in the event of injury is suggested for students who intend to participate in athletics at Shippensburg University. Shippensburg University will not be responsible for payment of any medical bills if the above procedures are not followed. This includes the student-athletes failure to follow their personal primary medical health insurance procedures for filing a claim. Any questions about a claim should be referred to the Department of Sports Medicine without delay. Shippensburg University, Shippensburg University Student Services, Inc., the Department of Athletics, and the Department of Sports Medicine will NOT be responsible for any medical bill received as the result of an athletic injury if the student-athlete does not have primary medical insurance. 1. PRE-PARTICIPATION PROCEDURES a. Insurance Information Form: Prospective student-athletes MUST have this form completed and returned to the Department of Sports Medicine for participation eligibility. NO student-athlete will be permitted to have a pre-participation physical examination unless the insurance information form has been completed and returned. b. NCAA Requirements: Prospective student-athletes MUST have completed all necessary forms required by the NCAA before a pre-participation physical examination will be given. c. Pre Participation Physical: Every student-athlete MUST have a pre-participation physical examination by the team physician on campus before participating in NCAA intercollegiate athletics at Shippensburg University. Student-athletes should contact their Coach or the Department of Sports Medicine for the date and time of the physical exam. Each candidate should report any irregularities, recent surgeries, fractures or any other pertinent medical information to the Etter Health Center and the Department of Sports Medicine. This would include any disabilities such as vision, hearing and oral defects. FAILURE TO REPORT THESE DISABILITIES WILL RESULT IN THE STUDENT-ATHLETE ASSUMING FULL RESPONSIBILITY FOR ANY INJURY INCURRED DUE TO PRIOR DISABILITIES. Student-athletes who have not received a current physical by the team physician will not be eligible to participate in NCAA intercollegiate athletics at Shippensburg University. If you should do so, Shippensburg University, Shippensburg University Student Services, Inc., the Department of Athletics, and the Department of Sports Medicine assumes no responsibility for any subsequent injury or treatment. STUDENT-ATHLETES WHO FAIL THE EXAMINATION MAY NOT PARTICIPATE IN NCAA INTERCOLLEGIATE ATHLETICS AT SHIPPENSBURG UNIVERSITY.

10 2. ATHLETIC RELATED INJURY a. Reporting Procedures: The student-athlete is responsible for reporting all injuries to the Department of Sports Medicine as soon as possible. The sports medicine staff will make all of the necessary medical referrals as indicated. In the event of an emergency the student-athlete will be transported to a hospital or medical facility. The student-athlete will at NO time seek outside medical attention for an athletic related injury without the prior consultation from the Department of Sports Medicine staff and/or the supervising team physician, except in the case of an emergency. In the case of HMO policies, the student-athlete may be required to follow specific referral procedures and every effort will be made to follow proper referral procedures. This may require the student-athlete to return home for an appointment with a participating HMO physician. Shippensburg University, Shippensburg University Student Services, Inc., the Department of Athletics, and the Department of Sports Medicine shall not be responsible for any charges incurred from an examination and/or treatment if these procedures are not followed. b. Dental Care: The Athletic Accident Insurance shall be responsible for injuries to the mouth and to sound, natural teeth incurred while participating in an official practice or game. In those sports where protective devices (mouthpieces) are mandatory and provided for use in official practice sessions and games, the Athletic Accident Insurance will assume responsibility ONLY if the protective device is worn by the student-athlete in accordance with the guidelines set by the manufacturer. DENTAL CARE NOT DIRECTLY RELATED TO AN ATHLETIC INJURY SHALL BE THE RESPONSIBILITY OF THE STUDENT-ATHLETE. c. Treatments: The athletic training facility hours will be posted. Failure of any injured student-athlete to keep a treatment or rehabilitation appointment will be interpreted as the student-athlete s unwillingness to cooperate with the Department of Sports Medicine. The head coach/coaching staff will be informed about the student-athlete s failure to cooperate. The Department of Sports Medicine staff receives its direction from the supervising team physician and the Director of Athletics. ALL STUDENT-ATHLETES are required to adhere to the Department of Sports Medicine Policies and Procedures. d. Out of Season/Non-Athletic-Related Injury: Shippensburg University, Shippensburg University Student Services, Inc., the Department of Athletics, and the Department of Sports Medicine shall NOT assume responsibility for the care of any injury incurred when the student-athlete is not actively engaged in a formal, official, sanctioned practice or game during an NCAA allowable season. Questions in this area should be referred to the Director of Athletics or the Director of Sports Medicine. e. Participation for an Injured or Ill Athlete: Decisions on the participation status of a student-athlete for a practice or competition shall be the sole responsibility of the supervising team physician and/or the licensed athletic trainer.

11 NCAA Banned Drugs and Medical Exceptions Policy Guidelines Regarding Medical Reporting for Student-Athletes with Attention Deficit Hyperactivity Disorder (ADHD) Taking Prescribed Stimulants The NCAA bans classes of drugs because they can harm student-athletes and can create an unfair advantage in competition. Some legitimate medications contain NCAA banned substances, and student-athletes may need to use these medicines to support their academics and their general health. The NCAA has a procedure to review and approve legitimate use of medications that contain NCAA banned substances through a Medical Exceptions Procedure. The diagnosis of adult ADHD remains clinically based utilizing clinical interviews, symptom-rating scales, and subjective reporting from patients and others. The following guidelines will help institutions ensure adequate medical records are on file for student-athletes diagnosed with ADHD in order to request an exception in the event a student-athlete tests positive during NCAA Drug Testing. 1. General considerations. Student-athletes diagnosed with ADHD in childhood should provide records of the ADHD assessment and history of treatment. Student-athletes treated since childhood with ADHD stimulant medication but who do not have records of childhood ADHD assessment, or who are initiating treatment as an adult, must undergo a comprehensive evaluation to establish a diagnosis of ADHD. There are currently no formal guidelines or standards of care for the evaluation and management of adult ADHD. The diagnosis is based on a clinical evaluation. ADHD is a neurobiological disorder that should be assessed by an experienced clinician and managed by a physician to improve the functioning and quality of life of an individual. a. Student-athletes should have access to a comprehensive continuum of care including educational, behavioral, psychosocial and pharmacological services provided by licensed practitioners who have experience in the diagnosis and management of ADHD. Studentathletes treated with ADHD stimulant medication should receive, at a minimum, annual clinical evaluations. b. Mental health professionals who evaluate and prescribe medical therapy for student-athletes with ADHD should have appropriate training and experience in the diagnosis and management of ADHD and should have access to consultation and referral resources, such as appropriate medical specialists. c. Primary care professionals providing mental health services (specifically the prescribing of stimulants) for student-athletes with ADHD should have experience in the diagnosis and management of ADHD and should have access to consultation and referral resources (e.g., qualified mental health professionals as well as other appropriate medical specialists). 2. Recommended ways to facilitate academic, athletics, occupational and psychosocial success in the college athlete with adult ADHD taking prescribed stimulants include: a. Access to practitioners experienced in the diagnosis and management of adult ADHD. b. A timely, comprehensive clinical evaluation and appropriate diagnosis using current medical standards.

12 NCAA Medical Exceptions Policy Reporting Guidelines January 30, 2009 Page No. 2 c. Access to disability services. d. Appropriate medical reporting to athletics departments/sports medicine staff. e. Regular mental health/general medical follow-up. 3. Student-Athlete Document Responsibility. The student-athlete s documentation from the prescribing physician to the athletics departments/ sports medicine staff should contain a minimum of the following information to help ensure that ADHD has been diagnosed and is being managed appropriately (see Attachment for physician letter criteria): a. Description of the evaluation process which identifies the assessment tools and procedures. b. Statement of the Diagnosis, including when it was confirmed. c. History of ADHD treatment (previous/ongoing). d. Statement that a non-banned ADHD alternative has been considered if a stimulant is currently prescribed. e. Statement regarding follow-up and monitoring visits. 4. Institutional Document Responsibility. The institution should note ADHD treatment in the student-athlete s medical record on file in the athletics department. In order to request a medical exception for ADHD stimulant medication use, it is important for the institution to have on file documentation that an evaluation has been conducted, the student-athlete is undergoing medical care for the condition, and the student-athlete is being treated appropriately. The institution should keep the following on confidential file: a. Record of the student-athlete s evaluation. b. Statement of the Diagnosis, including when it was confirmed. c. History of ADHD treatment (previous/ongoing). d. Copy of the most recent prescription (as documented by the prescribing physician).

13 NCAA Medical Exceptions Policy Reporting Guidelines January 30, 2009 Page No Requesting an NCAA Medical Exception: a. The student-athlete should report the banned medication to the institution upon matriculation or when treatment commences in order for the student-athlete to be eligible for a medical exception in the event of a positive drug test. b. A student-athlete s medical records or physician s letter should not be sent to the NCAA, unless requested by the NCAA. c. The use of the prescribed stimulant medication does not need to be reported at the time of NCAA drug testing. d. Documentation should be submitted by the institution in the event a student-athlete tests positive for the banned stimulant. Note: The NCAA Committee on Competitive Safeguards and Medical Aspects of Sports may approve stimulant medication use for ADHD without a prior trial of a non-stimulant medication. Although the NCAA Medical Exception Policy requires that a non-banned medication be considered, the medical community has generally accepted that the non-stimulant medications may not be as effective in the treatment of ADHD for some in this age group. The National Collegiate Athletic Association January 30, 2009 MEW:rhb

14 ATTACHMENT Attention Deficit Hyperactivity Disorder (ADHD) Guideline Attachment Criteria for letter from prescribing Physician to provide documentation to the Athletics Department/Sports Medicine staff regarding assessment of student-athletes taking prescribed stimulants for Attention Deficit Hyperactivity Disorder (ADHD), in support of an NCAA Medical Exception request for the use of a banned substance. The following must be included in supporting documentation: Student-athlete name. Student-athlete date of birth. Date of clinical evaluation. Clinical evaluation components including: o Summary of comprehensive clinical evaluation (referencing DSM-IV criteria) -- attach supporting documentation. o ADHD Rating Scale(s) (e.g., Connors, ASRS, CAARS) scores and report summary -- attach supporting documentation. o Blood pressure and pulse readings and comments. o Note that alternative non-banned medications have been considered, and comments. o Diagnosis. o Medication(s) and dosage. o Follow-up orders. Additional ADHD evaluation components if available: Report ADHD symptoms by other significant individual(s). Psychological testing results. Physical exam date and results. Laboratory/testing results. Summary of previous ADHD diagnosis. Other comments. Documentation from prescribing physician must also include the following: Physician name (Printed) Office address and contact information. Specialty. Physician signature and date. DISCLAIMER: The National Collegiate Athletic Association shall not be liable or responsible, in any way, for any diagnosis or other evaluation made, or exam performed, in connection herewith, or for any subsequent action taken, in whole or in part, in reliance upon the accuracy or veracity of the information provided hereunder. The National Collegiate Athletic Association January 30, 2009 MEW:rhb

15 Department of Sports Medicine Sickle Cell Trait Testing In accordance with the recent NCAA mandate, effective August 1, 2012, all Division II studentathletes must have knowledge of their sickle cell trait status prior to participation in intercollegiate athletics. Prospective student-athletes must provide documentation of test results for sickle cell trait to the Division of Sports Medicine at Shippensburg University or the studentathlete can decline to be tested and sign a written release. This mandatory documentation has been included in the student-athlete s required paperwork. Beginning August 1, 2012 a student-athlete may not practice or play his/her sport without providing the University the requisite documentation related to the status of the student-athlete s sickle cell trait. NCAA Bylaw: Sickle Cell Solubility Test. The examination or evaluation of student-athletes who are beginning their initial season of eligibility and students who are trying out for a team shall include a sickle cell solubility test (SST), unless documented results of a prior test are provided to the institution or the student-athlete declines the test and signs a written release. About Sickle Cell Trait Sickle cell trait is not a disease, but it is a life-long condition that will not change over time. Sickle cell trait is the inheritance of one gene for sickle hemoglobin and one for normal hemoglobin. Hemoglobin is the iron containing oxygen-transport protein in red blood cells. During intense or extensive exertion, the sickle hemoglobin can change the shape of the normally round red blood cell to an abnormal quarter moon or sickle shape. This change in the shape of the red blood cells can pose a serious risk for some student-athletes. During intense exercise, student-athletes with sickle cell trait have experienced significant physical distress, collapsed and even died. Research has shown that sickled red blood cells can clump and block normal blood vessels. This blockage can lead to the student-athlete s collapse from rhabdomyolysis, the rapid breakdown of muscles starved of blood. Heat, dehydration, altitude and asthma can increase the risk for the sickling of the red blood cells and worsen the symptoms, even when exercise is not intense.

16 Questions and Answers Q: Why should you get tested for sickle cell trait? A: This routine blood test is easily performed and can provide educational information that can be helpful to you on and off the field. Knowing your sickle cell status can allow health care professionals to take better care of you. If you were born in the United States, you should be able to acquire your testing results from your medical record with your local physician. Q: Is it mandatory that I have the sickle cell trait test? A: Shippensburg University Division of Sports Medicine recommends that every student-athlete be tested or show proof of prior testing for sickle cell trait. This testing needs to be obtained at home prior to the student-athlete arriving on campus for the academic school year. Please provide a copy of your test results with your preparticipation sports physical paperwork. Testing is not mandatory. If you choose to decline testing, you must sign a waiver stating that you are aware of the risks associated with the sickle cell trait and you understand the importance of testing, have declined it, and release Shippensburg University from any and all liabilities related to any loss or personal injury that may be a result from your non-compliance with the mandate of the NCAA and the Shippensburg University Department of Athletics. Q: What if I tested positive for sickle cell trait? A: The student-athlete will be counseled by our team physician if a student-athlete has a positive test result for the sickle cell trait. The student-athlete will be informed of the implications of the sickle cell trait and its effect on an individual participating in athletics. Student-athletes with a positive test result for sickle cell trait are permitted to participate in intercollegiate athletics. Q: Who will know that I have tested positive for sickle cell trait? A: As with all documents within the Division of Sports Medicine, individual results will be kept confidential in accordance with Shippensburg University policy and state laws. However, the Division of Sports Medicine staff and your particular team coaches will be made aware of your sickle cell trait status so that proper care is provided to you during all organized team conditioning, practices and competitions. There are three options to obtain this documentation: 1) Have the sickle cell trait testing completed by a physician at home prior to arrival on campus. The student-athlete will be responsible for any expenses incurred from testing. This is the preferred method to provide adequate documentation. 2) Provide documentation of test results if tested at birth. Contact your respective state health department (birth state) or pediatrician to obtain this documentation. The student-athlete will probably need to sign a release of information and complete other paperwork based on the requirements of the respective health department. This option could require you to wait for the requested results, which could delay the participation status of the student-athlete. Please plan ahead. 3) Sign the Sickle Cell Trait Testing Waiver and Assumption of Risk form. Signing this form acknowledges that you are aware of the facts and risks of sickle cell trait, have declined the recommendation of the Division of Sports Medicine at Shippensburg University to be tested and have knowledge of your sickle cell trait status. This waiver will be in effect throughout the student-athletes entire athletic participation at Shippensburg University.

17 Requirements for a student-athlete with a positive result for sickle cell trait 1. The student-athlete will sign the Sickle Cell Trait Positive Acknowledgement Form. 2. The student-athlete will watch the NCAA educational video about sickle cell trait and athletic participation. 3. The student-athlete will meet with the team physician to fully understand and discuss precautions, signs, symptoms, and concerns related to the sickle cell trait, with an emphasis on participation in sport. 4. Particular team coaches will be notified of the positive sickle cell trait status to ensure that the studentathlete is allowed access to fluids as needed, is not forced to participate in timed physical tests before becoming acclimated to heat and exertion at the beginning of a season, and any complaints of exhaustion will be taken seriously and activity stopped until a member of the sports medicine staff completes an evaluation.

18 First-Year and Transfers Only Department of Sports Medicine SICKLE CELL TRAIT TESTING WAIVER AND ASSUMPTION OF THE RISK FORM I,, understand and acknowledge that the NCAA and Print Name Shippensburg University Department of Athletics mandates that all student-athletes have knowledge of their sickle cell trait status. Additionally, I have read and fully understand the aforementioned facts about sickle cell trait and sickle cell trait testing. I understand that sickle cell trait does not prohibit me from participating in intercollegiate athletics. I recognize that ascertaining my true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries, ailments, and/or disabilities experienced. I hereby affirm that I have fully disclosed in writing any prior medical history, including my knowledge of sickle cell trait status to the Division of Sports Medicine at Shippensburg University. I wish to decline sickle cell trait testing as part of my pre-participation physical examination. Accordingly, I voluntarily agree to the maximum extent permitted by law, to release, forever discharge, indemnify and hold harmless Shippensburg University, its officers, employees and agents, and team physicians or their designees, from any and all costs, liabilities, expenses, claims, damages, actions, or causes of action related to any loss, personal injury, damage or property loss as a result of my non-compliance with the mandate of the NCAA and the Shippensburg University Department of Athletics. I am fully aware of the risks and hazards associated with sickle cell trait and exercise, which include, but are not limited to rhabdomyolysis and death, and willfully assume these risks. I am fully aware of the risks and hazards associated with refusing this testing and acknowledge that I am 18 years of age or older. If I am not 18 years or older, my parent or guardian has also signed this waiver. I am of sound mind and have carefully read this document before signing it. I fully understand that the NCAA and the Division of Sports Medicine at Shippensburg University recommended that I have knowledge and obtain my sickle cell trait status through testing, of which I have declined. Student-Athlete s Signature: Date Parent/Guardian Signature: Date (Required if student-athlete is under age 18)

19 Department of Sports Medicine Concussion Acknowledgement Form I,, acknowledge that I have to be an active participant in my own Print Name healthcare. As such, I have the direct responsibility for reporting all of my injuries and illnesses to the sports medicine staff (e.g., team physician, licensed athletic trainer, health center staff). I recognize that evaluating my true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries and/or disabilities experienced. I hereby affirm that I have fully disclosed, in writing, any prior medical conditions and will also disclose any future conditions to the sports medicine staff at my institution. I further understand that there is a possibility that participation in my sport may result in a head injury and/or concussion. I have been provided with education on head injuries and understand the importance of immediately reporting symptoms of a head injury/concussion to the sports medicine staff. By signing below, I acknowledge that my institution has provided me with specific educational materials on what a concussion is and has given me an opportunity to ask questions about areas and issues that are not clear to me on this issue. I have read the above and fully agree that the statements are accurate. Student-Athlete s Signature: Date Parent/Guardian Signature: Date (Required if student-athlete is under age 18)

20 SHIPPENSBURG UNIVERSITY DEPARTMENT OF SPORTS MEDICINE INSURANCE INFORMATION FORM Failure to complete all blanks will result in claims processing delays. Complete all blanks with information or n/a if not applicable. (SECTION 1) Name of Athlete: SU ID #: Home Address: City: State & Zip Code: (SECTION 2) Father/Guardian: Address: Date of Birth: (SECTION 3) Father/Guardian Employer: Address: Phone #: (SECTION 4) Record below if father/guardian is policy holder: Plan: Address: Phone #: Group #: Policy Number: Date of Birth: Age as of August 1: Men s Sport: Women s Sport: Home Phone #: Cell Phone #: Mother/Guardian: Address: Date of Birth: Mother/Guardian Employer: Address: Phone #: Record below if mother/guardian is policy holder: Plan: Address: Phone #: Group #: Policy Number: You must have medical insurance to participate in intercollegiate athletics at Shippensburg University. (Please enclose a copy of the front & back of the insurance card.) Please complete below: Is the plan listed above considered: q HMO q PPO q Neither Does the plan listed above have a deductible?: q Yes q No If yes, what is the deductible amount?: q $ Primary Care Physician: Address: Phone #: Any student-athlete who misrepresents or falsifies information regarding their primary insurance carrier will assume ALL financial liability for an injury incurred while participating in intercollegiate athletics at Shippensburg University. I hereby authorize Shippensburg University and their authorized agents to inspect or secure copies of case history records, laboratory reports, diagnosis, x-rays and any other data covering this and/or previous confinements or disabilities. A photostatic copy of this authorization shall be deemed as effective and valid as the original. We authorize Shippensburg University or their authorized agents to pay the medical vendors direct for any bills incurred from accidents that are covered under the coverage purchased by Shippensburg University. I have read the above information and fully understand its contents. I certify the above information is correct. If my insurance changes, I will notify the Department of Sports Medicine immediately. If the student-athlete is covered under his/her parents /guardians policy, the parent/guardian must notify the student-athlete and the Department of Sports Medicine of any insurance changes immediately. Primary Policyholder s Signature: Student-Athlete s Signature: Parent/Guardian Signature: (Required if student-athlete is under age 18) Date Date Date

21 Department of Sports Medicine Medical Examination and Authorization Form I hereby acknowledge, affirm, and represent that I have executed all of the NCAA compliance requirements to participate in intercollegiate athletics as a student-athlete at Shippensburg University. I hereby acknowledge, affirm, and represent that I have read and fully understand all of the information and documents provided by the Department of Sports Medicine to participate in intercollegiate athletics as a student-athlete at Shippensburg University. I further acknowledge, affirm, and represent the following: A. SHARED RESPONSIBILITY FOR SPORTS SAFETY. I understand that participation in sport requires an acceptance of risk of injury. I understand that there are certain inherent risks involved in participating in intercollegiate athletics at Shippensburg University and I assume responsibility for such risks. I rightfully assume that those who are responsible for the conduct of sport have taken reasonable precaution to minimize such risk and that their peers participating in the sport will not intentionally inflict injury upon them. The NCAA and individual sport-governing bodies make periodic analysis of injury patterns, refinements in the rules, and other safety decisions. However, to legislate safety via a rule book and equipment standards, while often necessary, seldom is effective by itself; and to rely on officials to enforce compliance with the rule book is as insufficient as to rely on warning labels to produce compliance with safety guidelines. Compliance means respect on everyone s part for the intent and purpose of a rule of guideline. B. PRESENT PHYSICAL CONDITION. Prior to my participation in intercollegiate athletics as a student-athlete at Shippensburg University I completed a Health History form and was examined by the team physician. Recognizing that my true physical condition (and the ability of the team physician to ascertain the same) is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints or ailments experienced I have fully disclosed in writing to the Department of Sports Medicine my prior medical history, which medical history is fully and accurately set forth in the completed Health & Orthopedic History forms. All present symptoms, complaints and ailments (if any) experienced by me have been disclosed in writing to, and discussed with the team physician. I am not suffering from any disability, injury, condition, complaint or problem not so disclosed and discussed. C. MEDICAL CONSENT. I have received instructions from the Director of Athletics and the Director of Sports Medicine to immediately report to the licensed athletic trainers any and all future injuries, medical problems, ailments, complaints, re-injuries, and aggravations of old injuries, no matter how minor or insignificant they may be. I hereby authorize the team physician (and/or such other physicians and licensed athletic trainers as Shippensburg University may designate) to perform customary orthopedic and medical examinations and to treat any athletic injuries, which I may sustain while participating in intercollegiate athletics as a student-athlete at Shippensburg University. Therefore, I am authorizing the licensed athletic trainers to render any treatment that may fall under the headings of preventative first aid, rehabilitation, and emergency treatment of any athletic injuries sustained while participating in intercollegiate athletics as a student-athlete at Shippensburg University. The licensed athletic trainer will be working under the direct supervision of the Shippensburg University team physician(s) and/or consulting physician(s). I realize that by giving consent for proper care, I am giving permission for hospitalization when necessary at an accredited hospital. D. AUTHORIZATION FOR RELEASE OF INFORMATION. I hereby authorize the Department of Sports Medicine and its representatives to examine, copy, and/or otherwise obtain copies of any and all medical records relating to my prior health history, injuries, complaints, tests, findings, and treatments. I hereby authorize all physicians, hospitals, clinics, schools, colleges, universities, and all other professional teams or organizations that may possess such records to make such records freely available to the Director of Sports Medicine and/or his/her representatives. I hereby release and discharge all such persons and institutions from any and all claims, which may arise by reason of transfer of said medical records. I authorize the transfer of said medical information via mail, fax, or . I hereby authorize the Director of Sports Medicine to transfer and forward my complete medical records and files to any other educational institution to which I may transfer. Such authorization shall extend, in addition to the Department of Athletics, to the team physician(s) and his/her successor(s), and all academic-related personnel, as well as to any hospital, clinic, or institution to which I may be referred or admitted in connection with any illness, injury, test, or treatment. I hereby release all such persons and institutions from any and all claims, which may arise by reason of transfer of said medical records and files. 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