How To Get A Degree From Delaware Valley University

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1 Dear New Del Val Student, The Health Service, Counseling Service and Athletic Training Department would like to congratulate you on your decision to attend Delaware Valley University. We look forward to assisting you with a smooth transition to college life. The Health and Wellness Center (SHWC) is located in Elson Hall. The Athletic Training Department is located across from Elson in the James Wok Gymnasium. More information regarding these services and our forms can be located on the DelVal web page and the MyDelVal student portal. In preparation for your arrival on campus please review and complete the documents included with this letter. Please submit your completed medical forms to the SHWC at the address below by August 1, All full-time students must have a completed Medical History, Emergency Contact form and Physician Validated Immunization Record. You can mail or fax the completed forms to the SHWC at the address or fax number below. All full-time students who are an Equine Management Major, plan to take an equine riding skills course, or planning to participate in an equine riding team (Hunt-Seat, Western, or Dressage) are required to submit an annual physical in addition to the Medical History, Emergency Contact and Immunization Record. If you intend to participate in intercollegiate sports please note that additional documents including a pre-participation physical are required annually by the Athletic Training Department (checklist or website for details). These forms are required to be on file before you are allowed to participate in any practices or competition. In addition the NCAA requires all student athletes to provide one time documentation of sickle cell status (test as infant or titer) be submitted. You can contact your state board of health or have lab work done during your physical to meet this requirement. Students who intend to participate in Del Val s intercollegiate sports should have their physical completed after June 1 st 2015 and returned to the SHWC by August 1, The University requires that all students have health insurance coverage. Please include copies of health insurance, Dental insurance and prescription cards (front and back sides) with the health form, as this is necessary to coordinate care outside the university setting. If you do not have your own health insurance coverage you will have to enroll in the student health plan offered by Delaware Valley University. If you are a full-time (12 or more credits) undergraduate student you must enroll or waive the University s health insurance plan (must be completed annually). If you do not go online starting June 1, 2015 and verify your insurance plan or enroll in the University plan by the deadline of September, 2015, you will be charged for the medical insurance. This charge is non-refundable.the enroll or waive process should be completed prior to your arrival to campus. The insurance coverage is effective through July 31 st Please contact Health Services (215) , Counseling Services (215) or Athletic Training Department (215) should you have any questions or concerns. You may also visit our websites at or for additional information. We wish you success and enrichment as you join the Delaware Valley University community. Sincerely, Miriam Torres RN, BS Sharon Donnelly Valerie Rice-Smith L-AT, ATC Director of Health Service Director of Counseling Head Athletic Trainer

2 Checklist for the Completion of Medical Forms and Insurance Information All incoming full-time freshman and transfer students must submit all Medical forms to the Health and Wellness Center and Enroll or Waive in the Student Health Plan by August 1 st for Fall semester (by January 10 th for Spring Semester). All Incoming Fulltime Freshman and Transfer students: Need to complete the following (Students who plan to participate in Intercollegiate Athletics or are an Equine Management Major, plan to take equine riding skills course or planning to participate in an equine riding team (Hunt-Seat, Western, or Dressage) must complete the additional forms as outlined below): Page 1 Combined, Emergency Contact, Insurance Information and Consent for Treatment Form - Signed by Student and Parent if the student is less than 18 years of age. Page 2 Report of Medical History Completed and signed by Student. Page 3 Immunization Record and TB screening form Documentation of TB screening and required immunizations completed.. Must be completed, signed and dated by student s medical provider. Submit Copies of Health Insurance, Dental and Prescription Drug Cards (front and back of cards) Complete On-Line enrollment or waiving of Student Health Insurance Plan - Students will be automatically charged for the Health plan. The charge will be removed when you waive the insurance if you have insurance of your own. You can access this site by clicking onto the following Health Service website: (site becomes available on June 1 st ). All full-time students who are an Equine Management Major, plan to take an equine riding skills course, or planning to participate in an equine riding team (Hunt-Seat, Western, or Dressage) are required to submit an annual physical (page 4) in addition to page 1-3 listed above ( Medical History, Emergency Contact Consent for treatment and Immunization Record. All Students considering participation in Intercollegiate Sports are required to complete pg. 1, 2, 3, an annual physical (page 4) (Athletic Physicals must be completed ON or AFTER June 1 st of the current year) and the following additional forms in order to participate in intercollegiate athletics. More information can be found on the Del Val Athletic Training website). Athletics Insurance Verification Form (pg.5) Signed by student and parent. Sickle Cell Reporting and Verification Form (pg. 6) The verification form is the actual test results. You only need this one time in your athletic career at Delaware Valley University. Athletics Concussion Acknowledgement Form (pg. 7) This is to be completed by the student athlete and the parent must sign if the student is less than 18 years of age. Athletics Medical Authorization, Release of information, and Consent and Release Forms (pg. 8) Signed by the student athlete. Parents must sign if the student is less than 18 years of age. ADHD Physician Form (pg. 9 if applicable) ONLY IF YOU ARE PRESCRIBED MEDICATION. More information on form. Return completed forms on Orientation day or Mail or Fax ( ) to: Delaware Valley University Student Health and Wellness Center 700 East Butler Avenue Doylestown Pa 18901

3 Completion of the Health Forms (all three pages) is mandatory for all new full-time freshman and all full-time transfer students. Please submit all forms directly; by fax or mail to the SHWC at the address above by August 1 st. Spring admission forms are due by January 10 st. / / F M ( ) - Last Name (print) First Name Middle Name Birth Date Gender (circle) Student Cell phone ( ) - Home Address (Number and Street) City State Zip code Student Home Phone ( ) - ( ) - In an Emergency Contact (Name) and Relationship Emergency Contact Cell Phone Emergency Contact Home Phone ( ) - ( ) - Mothers Name Cell or Home Phone Fathers Name Cell or Home Phone Insurance Information: Delaware Valley University has a mandatory health insurance requirement for all full-time students. (You will need to go on-line and enroll or waive prior to attending classes and annually). It is your responsibility to maintain current insurance information at the Health Center throughout your college career. It is also your responsibility to understand your health insurance plan (such as referral information, laboratory information, and in network providers (within the Doylestown area). Students assume the cost of healthcare not provided by the health center. These include radiology and laboratory services (such as blood work) and any outside health care provider evaluations. I plan to enroll in the Delaware Valley College sponsored Student Health Plan I already have health insurance and have verified that it will cover me at College Student Social Security number Name of Health Insurance Company Telephone number Insurance Company s Address Subscribers Name Relationship to Student (circle one) Self / Child / Spouse / Other Group number Policy number Identification number Does your insurance cover out of area non-emergent care? Yes No or Out of area provider? Yes NO Do you need a referral from your primary care physician for outpatient services? Yes NO Does your health insurance require the use of a specific laboratory for laboratory services? Yes NO If Yes, please check laboratory to be used: Quest Diagnostics or Lab Corp ****Please provide copies of Front and Back of Health, Dental and Pharmacy Insurance Cards**** Consent for Treatment: (Parental/Guardian permission must be obtained before medical treatment can be rendered to persons less than 18 years of age). Must be completed by parent/guardian: I give permission to the Consulting Physicians of Delaware Valley University to treat any illness or injury as may be necessary for my son/daughter (print name) and in the physicians absence for the nurse on duty to render emergency care and other medical care in line with standing orders, and also permit such procedures to be carried out at and by one of the local hospitals in the event that my son/daughter has been sent or taken there for emergency care. / / Signature of Parent/Guardian Print name and relationship Date Must be completed by student: I give permission to the Consulting Physicians of Delaware Valley University to treat any illness or injury as may be necessary for myself and in the physician s absence for the nurse on duty to render emergency care and other medical care in line with standing orders, and also permit such procedure to be carried out at and by one of the local hospitals in the event that I have been sent or taken there for emergency care. If I should be ill or injured and unable to sign the appropriate forms, I hereby give my permission for the Student Health Center to release information from my medical record to a physician, hospital or other medical agency involved in providing me with emergency treatment. / / Signature of Student Printed name Date 1

4 Report of Medical History *Please complete this form before going to your physician for examination* - - / / Last Name (print) First Name MI Social Security Date of Birth 1. Do you have Allergies to: (List and Include reaction) Medications: Yes No List: Environment: Yes No List: Food/Insects: Yes No List: 2. List All medications you are now taking (include over the counter, supplements, birth control pills, allergy serum, psychotropic) Name of Medication Dose Name of Medication Dose 3. List any illness or medical condition for which you are currently being treated. 4. List all hospitalizations or surgeries you have had. Family History: Have any of your relatives ever had any of the following? Disease Yes Relationship Disease Yes Relationship Cancer Heart Disease Diabetes High Blood Pressure Students Medical History: Please check all applicable items, whether current or past problem. Give details in the space provided Medical Problem Yes Details Medical Problem Yes Details Serious Eye Problems Heart Disease Serious Ear Problems Heart Murmur Asthma Irregular Heart Rhythm Pneumonia Anemia or Blood Disorder Severe Respiratory Infections High/Low Blood Pressure (specify) Frequent Sore Throats Abdominal or Intestinal problems Cancer Liver disease or Hepatitis Skin Disorder Kidney disease or Kidney Infection Skin Infection (Staph, MRSA, Herpes Ring Worm) (treated with medication) Kidney Stones Urinary Tract infection Concussion (when, how many) ADD/ADHD Head Injury with unconsciousness or Asperger Syndrome or Autism hospitalization? How long in hospital? Frequent or Severe Headaches Anxiety Seizure Disorder Depression Fainting or Dizziness Alcohol or other drug use Diabetes Treated by Psychiatrist/Counselor Thyroid Disease (hyper or hypo?) Mononucleosis Eating Disorder anorexia/bulimia Chicken Pox (had disease?) Age: Sickle Cell Disease or Sickle Cell Trait Tuberculosis Orthopedic injuries: Please check all injuries, location and provide details if had surgical repair Area ( Circle) Right Left Fractured Dislocated Date MRI X-ray Cat Scan Surgery (type of) Neck Back Knee Ankle Leg Foot Toe Shoulder Elbow Wrist Arm Hand Finger Other Statement by Student: I have personally supplied the above information and attest that it is accurate and complete to the best of my knowledge. I understand the information is strictly confidential and will not be released to anyone without my specific knowledge and written consent. Student Signature: Date of Birth: 2

5 Name Date of Birth / / THIS FORM MUST BE COMPLETED AND SIGNED BY YOUR HEALTH CARE PROVIDER Required Immunizations A. MENINGOCCAL Quadrivalent Required If the student first received the meningitis vaccine prior to turning 16 years of age, a second, or booster vaccine, is required. #1 / / #2 / / Mo Day Year Mo Day Year B. VARICELLA (Chicken Pox) Required (2 doses) (Birth in the U.S. before 1980, a history of chicken pox, a positive varicella antibody, or TWO doses of vaccine meets the requirement.) 1. History of Disease Yes No or Birth in the U.S. before 1980 Yes No 2. Varicella antibody / / Result: Reactive Non-reactive Mo Day Yr 3. Immunization a. Dose #1 / /, b. Dose #2 / / C. M.M.R. (Measles, Mumps, Rubella) Required (2 doses) Dose #1 / / #2 / / D. TETANUS-DIPHTHERIA-PERTUSSIS Required Primary series with booster with Tdap booster in the last ten years 1. Primary series completed / / 2. Tdap booster / / Mo Day Yr Mo Day Yr E. HEPATITIS B Required (Three doses of vaccine or positive hepatitis B surface antibody meets the requirement.) 1. Immunization (hepatitis B) Dose #1 / / Dose #2 / / Dose #3 / / 2. Immunization (Combined hepatitis A and B vaccine) Dose #1 / / Dose #2 / / Dose #3 / / 3. Hepatitis B surface antibody Date / / Result: Reactive Non-reactive Mo Day Yr F. POLIO Required Completion of primary series YES NO Date of last booster / / Recommended G. QUADRIVALENT HUMAN PAPILLOMAVIRUS VACCINE (HPV) Recommended Dose #1 / / Dose #2 / / Dose #3 / / H. HEPATITIS A Recommended Dose #1 / / Dose #2 / / Tuberculosis Screening (If the answer to question 1 or 2 is Yes proceed to additional evaluation to exclude active Tuberculosis disease) 1. Does the student have signs or symptoms of active pulmonary tuberculosis disease? Yes No 2. Is the student a member of a high-risk group? Yes No 3. Tuberculin Skin Test (PPD): Date: Result : ( record actual mm of induration) Positive Negative 4. Interferon Gamma Release Assay (IGRA) Date Obtained: Result: Positive Negative indeterminate borderline (T-Spot only) 5. Chest x-ray: (Required if TST or IGRA is positive): Date of chest x-ray: / / Result: Normal Abnormal Health Care Provider Name Signature Address Phone Date 3

6 Report of Physical Examination / / Last Name (print) First Name MI Date of Birth Sport Height: Weight: BP / Pulse Vision: Right / Left / Corrected: Y N **Sickle Cell Screening: Sickle Cell disease Yes No Sickle Cell Trait Yes No ** Documentation Mandated by the NCAA for student athletes (please attach copy of results)** Provider must complete date and sign this form - Please Check each item in the column provided Describe abnormal findings fully Area of Evaluation Normal Abnormal Please Describe Head, Face and Scalp Nose and Sinuses Mouth, Throat Ears / Hearing Eyes / Pupils Neck Heart Lungs, Chest, Breast Abdomen (include hernia) Gastro Intestinal Endocrine System Genitourinary Neurologic Psychiatric Musculoskeletal: Feet and Ankles Lower Extremities Upper Extremities Spine Is there loss or seriously impaired function of any paired organ? Yes No Describe Is the patient now under treatment for any medical or psychological condition? Yes No If Yes please explain: Is this student able to participate in inter-collegiate sports or horseback riding? Yes No if No what activities are to be eliminated or limited? Tuberculosis Screening (If the answer to question 1 or 2 is Yes proceed to additional evaluation to exclude active Tuberculosis disease) 1. Does the student have signs or symptoms of active pulmonary tuberculosis disease? Yes No 2. Is the student a member of a high-risk group? Yes No 3. Tuberculin Skin Test (PPD): Date: Result : ( record actual mm of induration) Positive Negative 4. Interferon Gamma Release Assay (IGRA) Date Obtained: Result: Positive Negative indeterminate borderline (T-Spot only) 5. Chest x-ray: (Required if TST or IGRA is positive): Date of chest x-ray: / / Result: Normal Abnormal Date: / / 4 Health Care Provider Signature: Provider Address Provider Telephone Number: Fax:

7 ATHLETIC S INSURANCE VERIFICATION FORM All Athletes are required to provide Health Insurance Verification Form each year. If you do not have health insurance you can purchase an insurance plan from the University. This completed Insurance Verification form and a copy of your INSURANCE CARD, Front and Back, must be received in the Athletic Training Department. If you have DENTAL INSURANCE please provide us a copy of your dental insurance card. Student Name Name of sport Social Security No. Date of Birth Home Phone Student Cell Phone HomeAddress Town/State Zip Code Parent(s)/Guardian(s) name Fathers work Phone Cell Phone Mother Work Phone Cell Phone Emergency Contact Phone number Primary Care Physician: Name: Address: Phone: Fax: A copy of current Insurance Card front and back is required! Insurance Co. Insurance Company Address Insurance Company Phone Number Policy # Group # ID # Subscriber s Name Subscribers Date of Birth Employer s Name Employers Address Dental Insurance Co. Dental Co. Address Dental Insurance Phone Number Policy # ID# Subscriber s Name I verify that I have health insurance and will maintain continuous coverage during enrollment. Student Signature Parent/Guardian Signature Date Date 5

8 Delaware Valley University Sickle Cell Trait - Reporting Form About Sickle Cell Trait: Sickle Cell Trait is an inherited condition of the oxygen-carrying protein, hemoglobin, in the red blood cells. Sickle Cell Trait is a common condition (> three million Americans) Although Sickle Cell Trait is most predominant in African-Americans and those of Mediterranean, Middle Eastern, Indian, Caribbean, and South/Central American ancestry, persons of all races and ancestry may test positive. An undiagnosed trait can be dangerous, even fatal. During intense, sustained exercise, hypoxia (lack of oxygen) in the muscles may cause sickling of red blood cells (red blood cells changing from a normal disc shape to a crescent or sickle shape), which can accumulate in the bloodstream and logjam blood vessels, leading to collapse from the rapid breakdown of muscles starved of blood and possible death. Twenty-one college football players with Sickle Cell Trait have collapsed and died over the past decade. If an athlete tests positive, he or she will still be able to participate in athletics activities with certain precautions. More information on Sickle Cell Trait may be found at the following NCAA website: Sickle Cell Trait Testing: The NCAA has mandated that all Division III student-athletes be tested for Sickle Cell Trait and show proof of a prior test, before participating in athletic-related activities, including intercollegiate athletics events, strength and conditioning sessions, practices, competitions, etc. Please PRINT your name, date of birth, and sport(s) below. Select one of the options below. Name: DOB: SPORT(S): A. A copy of my newborn screening records pertaining to Sickle Cell Trait are attached (this test was mandated for all Pennsylvania newborns beginning in September If you were born in another state, you will have to check their statute). B. A copy of my Sickle Cell Trait test from a physician or other authorized medical care provider is attached. Student athlete signature Parent signature if less than age 18 Date Date *** PLEASE REMEMBER TO ATTACH YOUR COPY OF EITHER YOUR SICKLE CELL TEST RESULTS OR COPY OF THE SCREENING RECORD *** 6

9 Concussion Acknowledgement In 2010, the NCAA mandated that all student-athletes sign a statement in which they accept the responsibility for reporting their injuries and illnesses to the institutional medical staff, including the signs and symptoms of a concussion. What is a concussion? It is caused by a blow to the head or body. Can be from contact with another player, hitting a hard surface (ground, floor, ice, etc.) or being hit by a piece of equipment (ball, lacrosse stick, etc.) or a car accident Can change the way your brain normally works Can range from mild to severe Presents itself differently for each athlete Can occur during practice, competition or conditioning in any sport and at home Can happen even if you DO NOT lose consciousness How can I prevent a concussion? Do not initiate contact with your head or helmet (you can still get a concussion even if you re wearing a helmet) Avoid striking an opponent in the head Follow your athletic department s rules of safety and the rules of the sport Practice good sportsmanship at all times Practice and perfect the rules of the sport What are the signs and symptoms of a concussion? Amnesia Confusion Headache Ringing in the ears Nausea or Vomiting Sensitivity to light or noise Feeling in a fog Irritability Concentration or memory problems (forgetting plays, facts, meeting times, etc.) Slow 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 to worsen or reappear. What should you do if you think you or a teammate might have a concussion? DON T HIDE IT! Report it to your athletic trainer and coach. Never ignore a blow to the head REPORT IT! DO not return to participation in game, practice or any other activity. The sooner you get checked out, the sooner you may be able to return to play GET CHECKED OUT! Your athletic trainer will be able to tell you if you have a concussion and have the authority and knowledge to determine when you can return to play TAKE TIME TO RECOVER! If you have had 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 concussion can cause permanent brain damage, and even death. By signing below, I state that I understand this concussion material. I also confirm that I shall always report any suspecting concussions o myself or others to the appropriate medical professionals. Student-Athlete Signature Print Student Athlete Name Date Sport Signature of Parent/guardian (if under 18) Print name of Parent/guardian (if under 18) Date 7

10 Athletic Training Authorization for Treatment and Consent for Release of Information Form Medical Authorization I/We hereby grant permission to Delaware Valley University and their physicians to render first aid treatment and medical or surgical care deemed reasonably necessary. I/We further authorize the Athletic Trainers at Delaware Valley University, who are under the direction and guidance of Gregory Gallant M.D., to render any first aid or preventative, rehabilitative, or emergency treatment deemed reasonably necessary. I/We additionally grant permission for hospitalization, treatment or surgery at a competent and/or accredited facility when necessary for the protection, health, and well-being of: Signature of Parent/Guardian: Signature of Student Athlete: Date: Date: Release of Information Authorization I/We hereby authorize Delaware Valley University administration, certified athletic trainers, physicians affiliated with DVC, and coaches to release medical information to my parents, insurance carriers, and NCAA research directors any illness or injury information relative to my past, present, or future participation in athletics at Delaware Valley University. I/We hereby authorize Delaware Valley University, Health Center Staff to release a copy of my Medical History and Physical Examination form to Del Val certified athletic trainers. I/We acknowledge that it is my responsibility to report any change in my health status to the certified athletic training staff throughout the entire academic school year. I/We also authorize any medical facility, physicians, or medical personnel who have attended to me to disclose when requested by Del Val, and all information regarding my illness or injury, medical history, consultation, diagnostic tests, treatment, recommendation, and copies of all hospital or medical records. A photo static copy of this authorization shall be considered valid and effective as the original. Signature of Parent/Guardian: Signature of Student Athlete: Date: Date: Consent and Release We, as students of Delaware Valley University and parents of students are aware that accidental injury may occur to a student athlete participating in a college sports program. This falls within the legal Assumption of Risk Doctrine. We know that the possibility of accidental injury could occur during sport participation and still view that the benefits of such programs outweigh the injury risk. Accordingly, we confirm our support of the sports program and, as a participant and parents of a participant, we hereby release the College, its employees and related personnel, of and from all claims whatever the nature of injury sustained by the student athlete during sport participation. In conjunction with treatment of accidental sport related injuries, we authorize, whenever determined by University personnel, to secure medical services for the injured student athlete. We authorize any attending physician to release confidential information concerning athletic related injuries to the medical staff of the University. Signature of Parent/Guardian: Signature of Student Athlete: Date Date 8 Athletic Training

11 ADHD Physician s Form The following is the recommended minimum requirements of required documentation from the prescribing physician to provide documentation to the Athletics Department/Athletic Training 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. For more information on this NCAA policy, please visit: Name: Current Clinical Evaluation Date: BP: / DOB: Pulse: Comments: ADHD Rating Scale: Patient Scores: Diagnosis: Medication/Dosage/Frequency: F/U Orders: Adderall and Ritalin are NCAA banned substances. Have other medications been considered? N or Y Comments: First Clinical Evaluation Date: BP: / Pulse: Comments: ADHD Rating Scale: Patient Scores: Diagnosis: Medication/Dosage: F/U Orders: Physician Information Printed Name: Specialty: Office Address: Phone Number: Physician Signature: Date: * Please attach a summary of the comprehensive clinical evaluation (reference DSM-IV criteria); a report summary concerning the ADHD rating scale used and the patient s scores, and a copy of the patient s current prescription. Requested information, if available: psychological testing results, laboratory testing results, any other additional comments. 9