NORTHWEST MISSISSIPPI COMMUNITY COLLEGE SPORTS MEDICINE PARTICIPATION PACKET

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1 SPORTS MEDICINE PARTICIPATION PACKET INSTRUCTIONS FOR FILLING OUT FORMS: 1. FILL OUT IN INK. 2. Complete all forms. 3. Make sure all forms are SIGNED. 4. Make sure all forms, copies, and/or faxes are legible and enlarged if possible. 5. You will not be able to participate until all forms or information is complete and turned in. THE FOLLOWING FORMS ARE TO BE COMPLETED: 1. Information Sheet 2. Sickle Cell Trait 3. Medical History 4. Physical Examination (by physician ONLY) 5. Insurance Information Sheet 6. Assumption of Risk/ Medical Insurance Authorization 7. Medical Consent/ Authorization for Release of Information 8. Helmet Warning (FOOTBALL ONLY) 9. A FRONT and BACK copy of your health insurance card. (Enlarged if possible) This includes MEDICAID, MILITARY, STATE INSURANCE, etc. Please return this packet to your coach. If you have any questions, please contact the Athletic Trainer.

2 Sports Medicine Information Sheet Date: Eligibility: (Circle One) 1 st Year / 2 nd Year / 3 rd Year Name: Last: First: Middle: Sport: Status: (Circle One) Scholarship / Walk-On / Transfer Social Security Number: - - DOB: / / Age: Home Address: Street: Apt #: City: State: Zip: Cell Phone #: Home Phone #: Emergency Contact Information: Contact Person # 1: Name: Address: Street: Relationship: Apt #: City: State: Zip: Cell Phone #: Secondary #: Contact Person # 2: Name: Address: Street: Relationship: Apt: City: State: Zip: Cell Phone #: Secondary #:

3 Sickle Cell Trait The National Athletic Trainers Association (NATA) and the College of American Pathologists (CAP), recommend that all student-athletes confirm their sickle cell trait status. Sickle cell trait is not a disease. It is an inherited condition where an individual has one normal gene for hemoglobin, and one abnormal gene. It is most predominant in African-Americans, and those of Mediterranean, Middle Eastern, Indian, Caribbean, and South and Central American ancestry, but persons of all races and ancestry may test positive. If an athlete tests positive, he or she may still be able to participate in athletics with certain precautions. They should see their athletic trainer for recommendations. Northwest Mississippi Community College (NWCC) mandates all student-athletes must do one of the following: Be tested for sickle cell trait Show proof of a prior sickle cell trait (with results) Sign a waiver releasing NWCC from liability Sickle Cell Trait Testing: Name: DOB: Sport: A copy of my sickle cell trait test results are attached I voluntarily decline to be tested, understand that an undiagnosed trait can be dangerous, even fatal, and agree to sign the waiver below. I,, acknowledge that NWCC mandates that all student-athletes be tested for sickle cell trait, show proof of a prior test, or sign a waiver releasing the school from liability if they decline to be tested prior to participation in athletically-related activities. Recognizing that my true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries, ailments, and/or other disabilities experienced. I hereby affirm that I have fully disclosed in writing any knowledge of sickle cell trait status to the NWCC Sports Medicine Staff. I do not wish to undergo sickle cell testing as part of my pre-participation physical exam and I voluntarily agree to release, discharge, indemnify and hold harmless the State of Mississippi, Northwest Mississippi Community College, its officials, employees, volunteers, and agents from any and all costs, liabilities, expenses, claims, demands, or causes of action on account of any loss or personal injury that might result from my voluntary decision not to be tested. I have read and signed the document with full knowledge of its significance. If I am under 18 years of age, my parent and/or guardian has also signed below. Student-Athlete Signature Date Parent or Guardian Signature (if under 18) Date

4 Medical History Form Name: DOB: Sport: Please list all of the prescription and over-the-counter medicines and supplements (herbal & nutritional) that you are currently taking: Please list any and all allergies you may have. (Including medicine, food, insects, pollen, etc.). If none, please write N/A. GENERAL QUESTIONS Yes No MEDICAL QUESTIONS Yes No 1. Has a doctor ever denied or restricted your participation in sports for any reason? 25. Do you cough, wheeze, or have difficulty breathing during or after exercise? 2. Do you have any ongoing medical conditions? 26. Have you ever used an inhaler? 3. Have you ever spend the night in the hospital? 27. Is there anyone in your family with asthma? 4. Have you ever had surgery? 28. Were you born missing any organs? HEART HEALTH QUESTIONS ABOUT YOU 29. Have you ever had a hernia? 5. Have you ever passed out or nearly passed out DURING 30. Have you had mononucleosis (mono)? or AFTER exercise? 6. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise? 31. Do you have any rashes, sores, or other skin problems? 7. Does your heart ever race or skip beats during exercise? 32. Have you had herpes or MRSA? 8. Has a doctor ever told you that you have any of the problems listed below? If so, circle: 33. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or High cholesterol Kawasaki disease Other memory problems? High blood pressure Heart murmur 9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram) 34. Have you ever had a head injury or concussion? 10. Do you get lightheaded or feel more short of breath than 35. Do you have a history of a seizure disorder? expected during exercise? 11. Have you ever had an unexplained seizure? 36. Do you have headaches with exercise? 12. Do you get more tired or short of breath more quickly than your friends during exercise? 37. Have you ever had numbness, tingling, or weakness in your arms or legs after a hit? HEART HEALTH QUESTIONS ABOUT YOUR FAMILY 38. Have you ever been unable to move? 13. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden 39. Have you ever become ill while exercising in the heat? death before age 50? 14. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator? 40. Do you get frequent muscle cramps when exercising? 15. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning? 41. Do you or someone in your family have sickle cell trait or disease? BONES AND JOINT QUESTIONS 16. Have you ever had an injury to a bone, muscle, ligament, or tendon that caused you to miss a practice or a game? 42. Have you ever had any eye injuries? 43. Have you had any problems with your eyes or vision? 17. Have you ever had any broken bones or dislocated 44. Do you wear contacts or glasses? joints? 18. Have you ever had an injury that required x-rays, MRI, 45. Do you wear protective eyewear such as CT scan, injections, therapy, a brace, a cast, or crutches? goggles or a face shield? 19. Have you ever had a stress fracture? 46. Do you worry about your weight? 20. Have you had an x-ray for neck instability or atlantoaxial 47. Are you trying to or has anyone instability? recommended that you gain or lose weight? 21. Do you regularly use a brace, orthotics, or other 48. Are you on a special diet or avoid certain assistive device? types of food? 22. Do you have a bone, muscle, or joint that bothers you? 49. Have you ever had an eating disorder? 23. Do any of your joints become painful, swollen, or red? Explain yes answers here: 24. Do you have any history of arthritis or connective tissue disease? FEMALES ONLY: Age of first menstrual period. When did your last menstrual period begin? How many periods have you had in the last 12 months? Do you take birth control pills? If so, which one(s)?

5 PRE-PARTICIPATION PHYSICAL EXAMINATION FORM NAME: Sport: DOB: Age: Height: Eyes/ Ears/ Nose/ Throat Weight: BP: / Pulse: MEDICAL EXAMINATION NORMAL ABNORMAL FINDINGS Heart/ Cardiovascular Pulmonary/ Lungs Abdomen/ Gastrointestinal Neurological Skin Genitourinary (Males Only) Other Neck MUSCULOSKELETAL EXAMINATION NORMAL ABNORMAL FINDINGS Shoulder/Arm Elbow/Forearm Wrist/Hand/Fingers Back Hip/Thigh Knee/Leg Ankle/Foot/Toes Other Cleared Not cleared Reason: Recommendations: Team Physician Signature: Date: (Ortho) Team Physician Signature: Date: (General)

6 Insurance Information Sheet **This form much be completed and signed for to be eligible to participate in athletics** *Please print except where signatures are asked for* Athlete s Name: Sport: DOB: Social Security #: Parent/Guardian(s) Name: Address: (Street Address) (City) (State) (Zip) Phone: Policyholders Name: Policyholders Social Security #: Employer: Relation to student-athlete: Policyholders DOB: Insurance Company Name: Street Address: City, State, Zip: Phone: ( ) ID/Member #: Group #: Type: HMO PPO POS Other Deductible Amount: Does this policy cover prescriptions? Yes No Does this policy include: Vision Dental Vision/Dental ID #: Vision/Dental Group #: Is preauthorization or referral necessary for medical/diagnostic services? Yes No I hereby authorize the Athletic Department to file a claim in my behalf for the athletic injury sustained while participating in sports under the above group medical policy. Further, I agree to consent that any amounts payable under this policy is paid to the medical provider or to Northwest Mississippi Community College Athletic Department as shown. Athlete is not covered under personal health insurance. Therefore, I hereby authorize Northwest Mississippi Community College Athletic Department, and its representatives to inspect, to secure copies of case history, laboratory reports, diagnosis, x-ray, and any other data in relation to any medical claim. This authorization may be copied and any photocopy should be deemed as valid and applicable as the original. Athlete Signature: Parent/Guardian Signature: Date: Date:

7 Assumption of Risk & Medical Insurance Authorization I am aware that playing or practicing to play/participate in any sport can be a dangerous activity involving many risks of injury. I understand that the dangers and risks of playing or practicing to play/participate in a sport include but are not limited to, death, serious neck and spinal injuries which may result in complete or partial paralysis, brain damage, serious injury to virtually all internal organs, serious injury to virtually all bones, joints, ligaments, muscles, tendons, and other aspects of the musculoskeletal system, and serious injury or impairment to other aspects of my body, general health, and well-being. I understand that the dangers and risks of playing or practicing to play/participate in sports may not only result in serious injury, but in serious impairment of my future abilities to earn a living, to engage in other business, social and recreational activities, and generally to enjoy life. I understand that it is my responsibility to adhere to all rules and regulations of my chosen sport. I understand that infraction of the rules may result in injury to my opponent or myself. I also understand that no modification of protective equipment or uniform should be made. In addition, I understand that it is my responsibility to report faulty or poor fitting equipment immediately to the coach, equipment manager, or athletic trainer. I understand that all injuries are to be reported to the athletic trainer. I understand that I am responsible for the follow-up care and treatment of injuries under the supervision of the athletic training staff. I accept the risks of participation in (sport) during the seasons. Athlete Signature: Parent/Guardian Signature: (If athlete is under 18) Date: Date: I fully understand that Northwest Mississippi Community College s (NWCC) athletic insurance policy is an excess policy. If the student-athlete is injured during a practice or game, and has medical insurance coverage, his/her policy will be used as the primary coverage. It is the responsibility of the athlete to file all necessary insurance papers or else the college cannot assume the financial responsibility of the injury. What the primary coverage does not cover, NWCC s excess policy will be responsible for the reasonable and customary outstanding balance. In the event that the student-athlete has no medical plan, then NWCC will become the primary coverage for the athlete if injured during athletic competition or practice. I hereby authorize the NWCC Athletic Department to file a claim on my behalf under the above medical insurance policy in the event an athletic related injury is sustained. By signing this release the athlete allows the sharing of medical information between his/her medical provider, coaches of athlete s sport and school administration. A photo static copy of this authorization shall be considered as effective and as valid as the original. Please check if the student-athlete is NOT covered under any medical insurance coverage. I have read the above and forgoing medical insurance information and understand the statements contained therein. Athlete Signature: Parent/Guardian Signature: (If athlete is under 18) Date: Date:

8 Medical Consent & Authorization for Release of Information Form Name: DOB: Sport: I authorize the certified athletic trainer(s), team physician(s), physical therapist, or other health care provider affiliated with Northwest Mississippi Community College (NWCC) to evaluate and treat any injuries that occur during my athletic participation at NWCC. This includes immediate first aid and treatment, diagnostic imaging, physical exam, surgery, hospitalization, follow up care, and rehabilitation in the NWCC Athletic Training Room as well as University Sports Medicine, Internal Medical Associates of Oxford, Oxford Diagnostic Center, Cornerstone Rehabilitation, or any other health care provider recommended by NWCC s medical staff. I further authorize my medical records to be released from the NWCC Sports Medicine staff to any of the health care providers listed above. I authorize the Sports Medicine staff to discuss my medical condition with coaches as it pertains to participation status, injuries sustained during participation, injury rehabilitation progress, and physical limitation. I authorize the Sports Medicine staff, including our team physicians, to discuss my health condition, including injuries and illnesses, with my parents and/or legal guardians. I understand that participation in athletic competition or practice is conditioned upon receiving medical clearance from a NWCC team physician. It is understood and agreed, however, that in the event that next of kin of said student-athlete are unavailable or cannot be present to authorize such surgery and related treatment, by execution of this agreement, the said next of kin of the within student-athlete authorize the duly constituted agents and employees of NWCC Department of Athletics to request and authorize surgery and related medical treatment for said student-athlete. Athlete Signature: Date: Parent/Guardian Signature: (If athlete is under 18) Date: TO ALL UNIVERSITIES, COLLEGES, ATHLETIC TRAINERS, PHYSICIANS, HOSPITALS, CLINICS, AND ALL OTHER AGENCIES AND HEALTH CARE PROVIDERS You are hereby authorized and requested to send the Northwest Mississippi Community College Sports Medicine Department a complete copy of all your records pertaining to my medical condition. This includes, but is not limited to, all physicals, athletic trainer s records, any diagnosis, treatment, injury, prognosis of any and all injuries, and to receive from you any and all other information pertaining to my past or present medical condition, diagnosis, treatment, history or prognosis from your personal knowledge and/or records. Any decision to revoke this authorization must be made in writing to the NWCC athletic trainer. Athlete Signature: Date: Parent/Guardian Signature: (If athlete is under 18) Date:

9 FOOTBALL ONLY WARNING WARNING WARNING WARNING WARNING WARNING THE FOLLOWING WARNING APPEARS ON ALL FOOTBALL HELMETS: DO NOT USE THIS HELMET TO BUTT, RAM, OR SPEAR AN OPPOSING PLAYER. THIS IS IN VIOLATION OF THE FOOTBALL RULES AND CAN RESULT IN SEVERE HEAD, BRAIN, AND/OR NECK INJURY, PARALYSIS OR DEATH TO YOU AND POSSIBLY INJURY TO YOUR OPPONENT. THERE IS A RISK THESE INJURIES MAY ALSO OCCUR AS A RESULT OF ACCIDENTAL CONACT WITHOUT THE INTENT TO BUTT, RAM, OR SPEAR. NO HELMET CAN PREVENT ALL SUCH INJURIES. The above warning appears on each football helmet to inform you that football is a dangerous sport. By participation in football you could become injured with death or permanent paralysis as the end result. Paralysis is the condition where one cannot move one or more parts of their body due to injury of the spinal cord and/or related structures. Permanent paralysis is forever. When one is paralyzed they are often referred to as: PARAPLEGIA- Paralysis of the lower portion of the body and/or both legs due to injury to the spinal cord and related structures. QUADRAPLEGIC- Paralysis affecting both arms and both legs. Paralyzed from the neck down. Athlete s Signature Date Athlete: Print name here:

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11 Please provide a copy FRONT and BACK Of all Insurance Cards and Prescription Cards.

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