University of South Alabama Sports Medicine Tryout Requirements

Transcription

1 University of South Alabama Sports Medicine Tryout Requirements Please Complete the Following Tasks by: Complete the attached paperwork containing the following documents: o Intercollegiate Athletic Tryout Waiver Form o Medical History Questionnaire o AHA Questionnaire o Sickle Cell Trait Information Sheet / Waiver o Medical Insurance Information Sheet Make an Appointment with Student Health Center at (251) for a Pre-Participation Physical Exam (PPE) and Sickle Cell Solubility Test (if needed). o Complete the following paperwork Prior to your PPE appointment AHA sheet questions 1-8 Only General Medical History o Bring completed paperwork along with Pre-Participation Physical Exam Form to your appointment. o Cost for PPE - approximately$20 o Cost for Sickle Cell Solubility Test approximately $48 Return Completed Paperwork back to Athletic Training Room after PPE and Sickle Cell Testing (if needed) has been completed along with a copy of your Insurance Card (Front and Back) <<<Student Health Services Map to Student Health Services.

2 South Alabama Athletics Proof of valid health insurance that covers athletic injuries All Primary Insurance policies are subject to approval by the athletic department and must be considered a major medical health care policy o Supplemental short term policies are NOT accepted o Policies cannot exclude athletic injuries All policies must have out of network benefits o Allows treatment by Mobile physicians o Out of network policies must have guesting privileges *A copy of the front and back of the insurance card must be presented at the time of tryout. If a prospective walk-on athlete does not have valid health insurance that covers athletic injuries, he or she will not be able to participate until they have done so. Examples of insurance NOT accepted: Military based insurance o Ex: Tricare Government based insurance o Ex: Medicaid Supplemental insurance policies o Ex: Aflac Kaiser Permanente is Not accepted

3 UNIVERSITY OF SOUTH ALABAMA INTERCOLLEGIATE ATHLETIC TRYOUT RELEASE FORM Student Athlete: Date: Sport: Jaguar ID: I,, wish to try out for a position with a University of South Alabama Intercollegiate Athletic Team. I understand and assume the accompanying risk of physical injury or death from such athletic activity. I or my heirs, executors, administrators or assigns release the University of South Alabama, it s employees and representatives, from all claims and/or liability whatsoever for any injuries, illnesses or death resulting from such athletic tryouts. I have no knowledge of any physical impairment or disability that would affectmy participation in the above tryout. I acknowledge that I MUST show proof of and provide the following information: A copy of a current, valid and approved by athletics medical health insurance card A pre-participation physical exam by USA physicians at student health services Complete a Sickle Cell Trait test. The NCAA requires all tryout participants to complete a Sickle Cell Solubility test, show results of a prior test, or sign a waiver releasing the university from liability if you decline to be tested. ALL INFORMATION MUST BE RETURNED TO THE DESIGNATED INTERCOLLEGIATE SPORT-ATHLETIC TRAINER PRIOR TO ANY PHYSICAL ACTIVITY. Athlete s Signature Date Parent/Guardian s Signature (If under 19 years old) Date

4 UNIVERSITY OF SOUTH ALABAMA DEPARTMENT OF ATHLETICS MEDICAL HISTORY QUESTIONNAIRE Please answer all of the following questions in detail. Incomplete forms may be returned to you resulting in a delay in your physical process. This process must be complete before you will be allowed to participate. NAME: Sex: DATE OF BIRTH: / / Last, First Middle mm ddyyyy SSN: - - JAGUAR ID#: SPORT(S): (At USA) Primary Secondary Tertiary LOCAL ADDRESS: (AT USA) City State Zip LOCAL PHONE: ( ) CELL PHONE: ( ) ADDRESS: PARENTS NAMES: Mother Father PARENTS HOME PHONE: ( ) ( ) PARENTS CELL PHONE:( ) ( ) PARENTS WORK PHONE: ( ) ( ) ADDRESS: HOME ADDRESS: (Permanent) City State Zip IN CASE OF EMERGENCY, PLEASE CONTACT: (other than parent/guardian) NAME: RELATIONSHIP: HOME PHONE:( ) WORK PHONE: ( ) CELL PHONE:( )

5 UNIVERSITY OF SOUTH ALABAMA PRE-PARTICIPATION PHYSICAL EXAM FORM ATHLETE S NAME: JAGUAR ID: SPORT: DATE OF BIRTH: Year 1 Year 2 Year 3 Year 4 Year 5 TYPE OF EXAM FULL EXAM VITAL SIGNS FULL EXAM VITAL SIGNS VITAL SIGNS ACDM. YEAR EXAM DATE HEIGHT In. In. In. In. In. WEIGHT Lbs. Lbs. Lbs. Lbs. Lbs. VISION TEMPERATURE BP / / / / / PULSE /min. /min. /min. /min. /min. GENERAL MEDICINE PHYSICAL: YEAR 1 Normal Abnormal Findings/Comments M.D. Initials EENT HEAD HEART LUNGS ABDOMEN SKIN Cleared for full participation with no restrictions Cleared with limitations/restrictions: Not cleared due to: Physician s Signature: Physician: Date: ORTHOPEDIC PHYSICAL Normal Abnormal Findings/Comments M.D. Initials HEAD & NECK SPINE SHOULDERS ELBOWS ARMS WRIST/HAND PELVIS QUAD/HAM KNEE ANKLE/FOOT Cleared for full participation with no restrictions Cleared with limitations/restrictions: Not cleared due to: Physician s Signature: Physician: Date: GENERAL MEDICINE PHYSICAL: YEAR 3 ONLY Normal Abnormal Findings/Comments M.D. Initials EENT HEAD HEART LUNGS ABDOMEN SKIN Cleared for full participation with no restrictions Cleared with limitations/restrictions: Not cleared due to: Physician s Signature: Physician: Date:

6 Name Jaguar ID D.O.B The 12 Element AHA Recommendations for Pre-participation Cardiovascular Screening of Competitive Athletes Student- Athlete please answer Yes or No to the following 8 questions: Medical historyabout YOURSELF and Family History: Personal history Have you ever experienced: Yes - No 1. Exertional chest pain/discomfort Yes - No 2. Excessive exertional and unexplained dyspnea/fatigue, associated with exercise Yes - No 3. Unexplained syncope/near-syncope Yes - No 4. Elevated systemic blood pressure Yes - No 5a. Prior recognition of a heart murmur Yes - No 5b.Heart surgery or diagnosed conditions of the heart Family history Do any family member have or have experienced Yes - No 6. Premature death (sudden, unexpected, or otherwise) before age 50 years due to HEART DISEASE, in 1 relative Yes - No 7. Disability from HEART DISEASE in a close relative <50 years of age Yes - No 8. Specific knowledge of certain cardiac conditions in family members: hypertrophic or dilated cardiomyopathy, long-qt syndrome or other ion channelopathies, Marfan syndrome, or clinically important arrhythmias Physical examination FOR DOCTORS ONLY! Yes - No 9. Heart murmur Yes - No Yes - No Yes - No 10. Abnormal femoral pulses to exclude aortic coarctation 11. Physical stigmata of Marfan syndrome 12. Abnormal brachial artery blood pressure (sitting position) BP/Left Arm BP/ Right Arm *Parental verification is recommended for high school and middle school athletes. Judged not to be neurocardiogenic (vasovagal); of particular concern when related to exertion. Auscultation should be performed in both supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction. Preferably taken in both arms. 37 Physician recommendation for cardiac follow up YES or NO Evaluation Notes: Evaluated By: Physician Name Physician signature Date of Evaluation

7 GENERAL MEDICAL Please circle any of the following that you currently have; have had, and/or are currently being treated for: Anemia Heat Illness (Cramps, Exhaustion, Etc.) Migraines Appendicitis Hemophilia Mononucleosis Bladder Illness/Injury Hepatitis Mumps Bleeding Tendencies Hernia Palpitations Chicken Pox Hiatal Hernia Pleurisy Diabetes High/Low Blood Pressure Pneumonia Drug/Alcohol Dependency HIV/AIDS Polio Emotional Disturbance (Depression) Kidney Disease/Injury Spleen Injury Epilepsy Leukemia Stomach Trouble Freq. or Severe Headaches Liver Disease/Injury Sickle Cell Trait Fibromyalgia Lupus Tuberculosis Hearing Defect Measles Thyroid Disorder Heart Disease/Heart Surgery Menstrual Disorder Ulcers Please explain ANY of the circled responses: GENERAL MEDICAL PLEASE COMPLETE THE FOLLOWING QUESTIONS: YES NO Have you ever lost a paired organ (i.e.: kidney, eye, testicle, etc...? YES NO Have you ever been told that you should wear a brace, be taped, etc.? YES NO Have you ever been told to have a test or surgery that you did not elect to do? YES NO Have you ever been in a car accident that you were injured? YES NO Have you ever been denied participation in a sport? YES NO Do you have any other medical problems not mentioned above? YES NO Have you ever passed out while exercising? YES NO Have you ever passed out for any reason? YES NO Do you frequently cough after exercising? YES NO Have you ever had chest pain while exercising? YES NO Have you ever been diagnosed with a heart condition, rhythm defect, or suffered a heart attack? YES NO Have you ever seen a cardiologist, pulmonologist, or neurologist? YES NO Has anyone in your family died before the age of 50? YES NO Are there any diseases that run in your family (diabetes, heart disease, etc...)? YES NO Have you ever been told or you have suspected you have an eating disorder? YES NO Do you have any screws, pins, pacemaker, or other implants? YES NO Are you currently taking any medications regularly? YES NO Have you been told to take a medication that you no longer take? YES NO Are you now or have you ever used an anabolic steroid or growth hormone? YES NO Have you ever suffered an injury to your genital/groin area?

8 VISION AND DENTAL YES NO Do you wear dentures, partials, retainers, etc.? YES NO Do you have full use of both eyes? YES NO Do you wear contacts or glasses? ALLERGIES YES NO Are you allergic to any medications that you are aware of? Please circle all that apply: Aspirin, Codeine, Cortisone, Sulfa, Anti-Inflammatory Medications, or Penicillin. Other Medication Not Listed: YES NO Hay Fever? YES NO Insect Bites or Stings? If yes, what kind of insect(s)? YES NO Any particular food? Explain: YES NO Other Allergies? Explain: HEAD YES NO Have you ever been knocked unconscious? YES NO Were you admitted to a hospital or infirmary? YES NO Did you miss any practice or game time due to a head injury or pain? YES NO Have you ever had a concussion without losing consciousness? YES NO Have you ever had a seizure (either convulsive or non-convulsive)? NECK YES NO Have you ever had a neck injury or neck pain? YES NO Were you admitted to a hospital or infirmary? YES NO Did you miss any practice or game time due to a neck injury or pain? BACK YES NO Have you ever injured your back or suffered from back pain? YES NO Did you miss any practice or game time due to a back injury or pain?

9 SHOULDER YES NO Have you ever had a shoulder injury? R L YES NO Did you miss any practice or game time due to shoulder injury or pain? ARM/ELBOW YES NO Have you ever injured either one of your elbows? R L YES NO Were you put into a cast or immobilized? YES NO Did you miss any practice or game time due to arm/elbow injury or pain? WRIST/HAND/FINGERS YES NO Have you ever injured either one of your wrists/hands/fingers? R L YES NO Were you put into a cast or immobilized? YES NO Did you miss any practice or game time due to shoulder injury or pain? HIP/THIGH YES NO Have you ever injured either of your hips? R L YES NO Were you put into a cast or immobilized? YES NO Did you miss any practice or game time due to hip injury or pain?

10 KNEE YES NO Have you ever injured either of your knees? R L YES NO Were you put into a cast or immobilized? YES NO Did you miss any practice or game time due to knee injury or pain? LOWER LEG/ANKLE YES NO Have you ever injured your ankle(s)? R L YES NO Were you put into a cast or immobilized? YES NO Did you miss any practice or game time due to lower leg/ankle injury or pain? Please explain any of the YES answers: FEET YES NO Have you ever injured either foot? R L YES NO Did you miss any practice or game time due to foot injury or pain? YES NO Have you ever been told that you have flat feet or high arches? YES NO Have you ever used, or been advised to use orthotics? Please explain any of the YES answers: List and describe ANYOTHER injuries you have sustained, giving dates for all and explaining their occurrence and any current medical problems that you would like to speak with the physicians about:

11 WOMEN ONLY Female Student-Athletes complete the following: YES NO Do you suffer from irregular menstrual periods? YES NO Do you suffer from severe menstrual cramps? YES NO Are you currently taking any medications for birth control and/or severe cramps? If yes, what, how much and how often? YES NO Do you have frequent urinary tract infections? YES NO Have you had any past pregnancies or births? YES NO Have you ever been treated for anemia (low iron)? YES NO Have you ever been treated for an eating disorder? IT IS THE POLICY OF THE UNIVERSITY OF SOUTH ALABAMA DEPARTMENT OF ATHLETICS THAT STUDENT ATHLETES WHO HAVE A MEDICALLY DIAGNOSED PREGNANCY NOT PARTICIPATE IN ANY UNIVERSITY ATHLETIC DEPARTMENT SPONSORED COMPETITION, PRACTICE, OR CONDITIONING ACTIVITY IF PARTICIPATION WOULD PRESENT AN UNREASONABLE DANGER TO EITHER THE FETUS OR THE MOTHER. IN THE EVENT OF A PREGNANCY; THE UNIVERSITY, ITS TEAM PHYSICIANS OR DESIGNATED PHYSICIANS MAY RESERVE THE RIGHT TO HOLD A STUDENT ATHLETE OUT OF PARTICIPATION FOR SUCH REASONS. STUDENT ATHLETE,, AND PARENT OR GUARDIAN HAVE READ, UNDERSTAND AND AGREE TO THE AFOREMENTIONED POLICY ON THE PARTICIPATION OF THE STUDENT ATHLETE. STUDENT ATHLETE AND PARENT OR GUARDIAN AGREE THAT IT IS THE STUDENT ATHLETE S RESPONSIBILITY TO NOTIFY THE UNIVERSITY S MEDICAL PERSONNEL OF ANY CHANGE IN MENSTRUAL PERIODS AND/OR REPRODUCTION STATUS. STUDENT ATHLETE AND PARENT OR GUARDIAN UNDERSTAND THAT THE UNIVERSITY DEPARTMENT OF ATHLETICS MAY NOT BE HELD FINANCIALLY RESPONSIBLE FOR ANY PREGNANCY TESTS OR OTHER MEDICAL PROCEDURE THE STUDENT ATHLETE MAY UNDERGO DUE TO CHANGES IN THE STUDENT ATHLETE S REPRODUCTIVE SYSTEM. DATE: PARENT OR GUARDIAN S SIGNATURE REQUIRED IF UNDER 19 YEARS OF AGE SIGNATURE: SSN: PARENT/GUARDIAN:

12 Sickle Cell Trait Testing: University of South Alabama Sports Medicine Sickle Cell Trait Information Sheet/Waiver Revised August 2013 The NCAA requires that all Division I student-athletes who are beginning their initial year of eligibility and student athletes trying out for an intercollegiate team, including transfer student-athletes to complete a sickle cell solubility test, show results of a prior test, or sign a waiver releasing the school from liability if they decline to be tested. Sickle cell solubility test results or waiver must be completed before participating in athletic-related activities, including intercollegiate athletics events, strength and conditioning sessions, tryouts, practices, or competitions. Division I Bylaw Please insert your name, date of birth, and sport below then select one of the options below and return this form and the supporting documentation. Name Last First Middle Sport(s): J# Date of Birth / / Please choose ONE of the following: A. I would like to be tested by the USA sports medicine staff as part of my pre-participation physical examination. I understand that there may be a delay in my medical clearance and that the results will be shared with the team physician. IF YOU CHOSE THIS OPTION YOU MUST SIGN OPTION A BLOOD SOLUBILITY TESTINGBELOW. OPTION A Sickle Cell Solubility Test (only needed if Blood SolubilityTestingis selected above): I hereby authorize the University of South Alabama Sports Medicine staff to obtain a blood screen, and to use, disclose, or obtain protected health information (PHI) from my medical record. This consent and authorization may include, but is not limited to the release of psychological, psychiatric, alcohol, drug abuse, HIV/AIDS, and sickle cell information. I hereby grant permission to the University of South Alabama athletics and consulting physicians to store my medical information within the department of athletics in my medical records, and at the USA comprehensive sickle cell center on the database. Student Signature: DATE / / Parent or Guardian Signature DATE / / (Required if student athlete is under 19 years of age) B. A copy of my newborn screening records pertaining to sickle cell trait are attached. C. A copy of my sickle cell trait test from a physician or other authorized medical care provider is attached. D. TheUniversity of South Alabama Sports Medicine staff has a copy of my sickle cell trait test. I, the undersigned, have read this release and understand its terms. I execute it voluntarily and with full knowledge of its significance. If I am under 19 years of age, my parent and/or guardian has also signed below. Student Signature: DATE / / Parent or Guardian Signature DATE / / (Required if student athlete is under 19 years of age)

13 INSURANCE AND FINANCIAL RESPONSIBILITY ALL UNIVERSITY OF SOUTH ALABAMA INTERCOLLEGIATE STUDENT-ATHLETE PARTICIPANTS MUST BE COVERED BY A MAJOR MEDICAL HEALTH INSURANCE THAT HAS BEEN APPROVED BY JAGUAR ATHLETICS BEFORE PARTICIPATING IN ANY PRACTICE, GAME, AND/OR COMPETITION. The student-athlete s health insurance policy must cover PARTICIPATION in intercollegiate athletics and have an inclusion for intercollegiate athletic related injuries and/or illnesses, and shall be considered the PRIMARY insurance coverage for all athletic related injuries. Some insurance companies may be impermissible due to the compatibility with the athletic institutional excess athletic coverage, (i.e. TRICARE, KEISER, MEDICAID). Please discuss with the sports medicine staff if you have any questions. The student-athlete must complete a Health Insurance Information / Authorization Form and supply a photocopy (front & back) of the health insurance card on a yearly basis. South Alabama Athletic Department carries an excess accident medical insurance which provides excess medical coverage for injuries incurred by student-athletes while participating in an intercollegiate sponsored /supervised activity. The student-athlete is required to have primary insurance through another source, the excess accident medical policy applies toward those expenses not covered by the primary policy. Mutual of Omaha is the insurer and claims manager for this program.the Master Policy on file at the University contains all of the provisions, limitations, exclusions, and qualifications of the University of South Alabama insurance policy, some of which may not be included in the brochure. If any discrepancy exists between this brochure and the Policy, the Master Policy will govern and control the payment of benefits. THIS POLICY, HOWEVER, IS SECONDARY TO, OR IN EXCESS OF, PERSONAL FAMILY MEDICAL INSURANCE COVERAGE, and covers ONLY injuries / illnesses / accidents resulting from the direct participation in the intercollegiate athletics program during the dates of the primary competitive season and designated off-seasons as approved by the Director of Athletics according to NCAA regulations. The policy provisions include a benefit period for 104 weeks (2years) from the documented time of injury. No benefits will be paid beyond the policy limits.the NCAA provides a catastrophic insurance program for student-athletes. Exclusions and Limitations: University of South Alabama s secondary medical insurance policy WILL NOTapply to the situations indicated below. This list is not all-inclusive. 1. Injuries / Illnesses that are not the direct result of intercollegiate athletics participation during the dates of the primary competitive season and designated off-seasons as approved by the Director of Athletics according to NCAA 2. Experimental procedures or Cosmetic surgery or procedures unless directly related to an athletic related injury 3. Hospital room and board charges in excess of the semi-private room rate unless hospitalized in an intensive care unit. 4. Injuries / illnesses that are a result of intramural, club sports, and recreational activities (non-intercollegiate activities), as well as training / conditioning activities that occur outside of the primary competitive season and designated off-season periods. 5. Injuries / illnesses that are recurrences of old injuries / illnesses which were sustained before participation in the intercollegiate sports program, or expenses for athletic injuries incurred after completion of the student-athlete s intercollegiate athletic eligibility. 6. Medical expenses beyond the limitations and exclusions of, or not covered by the University of South Alabama Department of Athletics insurance policy. The importance of having some form of personal health insurance coverage cannot be overemphasized. Medical bills resulting from the aforementioned activities will be submitted to the student-athlete s primary medical insurance. Any unpaid balances are the responsibility of the student-athlete and/or the student-athlete s parent(s) / guardian(s) Compliance with Insurance Company Requests: It is the student-athlete s and his/her parent(s) / guardian(s) responsibility to understand the conditions that apply to their policy and comply with any request for information, etc. from the primary insurance company. Insurance companies request information on their policy holders when injury / illness medical claims are billed. Examples are, but not limited to, accident/injury questionnaires mailed to your home asking you to answer and mail back to the insurance company and/or student enrollment verification, proving he/she is in college. Any delinquent bills resulting in bad credit due to non-compliance with insurance company requests will be the responsibility of the student-athlete. In the event that a student-athlete and/or his/her parent(s) / guardian(s) receives payment / reimbursement directly from their insurance company for athletic related injury / illness claims, the full account balance becomes the responsibility of the student-athlete and/or his/her parent(s) / guardian(s), until payment is turned over to the provider. HMOs: If a student-athlete s primary insurance is an HMO, the University of South Alabama Athletic Training Department strongly encourages the studentathlete and/or his/her parents(s) / guardian(s) to change the primary care physician (PCP) to a University of South Alabama Team Physician or local physician who is possibly in your network. Some HMO policies have away from home care when the student-athlete is out-of-network. Please call your insurance company s customer service department for questions and relocation of your PCP. This will allow the student-athlete to have a network of physicians in the South Alabama area, as well as better access to care. Insurance Policy Changes: University of South Alabama Athletic Training Department must receive any changes to a health insurance policy as soon as they occur. If proper notification is not received, the University of South Alabama Athletic Training Department will not be responsible for any delays in payment, collections notices, credit reports, etc. that occur. If a cancellation of a policy occurs without proper notification, all bills incurred during that period will be the responsibility of the student-athlete and/or his/her parents(s) / guardian(s). Medical Bills: In the event that a student-athlete should receive a bill / statement for an injury / illness that occurred as a direct result of participation in intercollegiate athletics at University of South Alabama, the student-athlete must submit the bill / statement to his/her certified athletic trainer within 20 business days of receipt. Bills received after 20 business days will be the responsibility of the student athlete and/or the student athlete s parents(s)/guardian(s). I understand and acknowledge the above provisions related to primary insurance coverage, changes, and out of network provisions. Student- Athlete Name: Sport: Student Signature: DATE / / Parent or Guardian Signature DATE / / (Required if student athlete is under 19 years of age)

14 University of South Alabama Sports Medicine Medical Insurance Information (To be completed by student athlete s parent or guardian) Athlete s Name: Social Security #: Jaguar ID: D.O.B.: Sport(s): A COPY OF THE FRONT AND BACK OF YOUR INSURANCE CARD(S) IS MANDATORY PARENT/GUARDIAN INFORMATION Father/Guardian: Mother/Guardian: Social Security #: Social Security #: Address: Address: Home Phone: Home Phone: Cell Phone: Cell Phone: Employer: Employer: Address: Address: Work Phone: Work Phone: PRIMARY INSURANCE(REQUIRED FOR PARTICIPATION) SECONDARY INSURANCE Insurance Carrier: Insurance Carrier: Name of Insured: Name of Insured: D.O.B.: D.O.B.: Policy Number: Policy Number: Group/Plan Number: Group/Plan Number: Effective Date: Effective Date: Insurance Co. Address: Insurance Co. Address: Insurance Co. Phone Number: Insurance Co. Phone Number: Is this plan an: HMO?Y ( ) N ( ) PPO? Y ( ) N ( ) Is this plan an: HMO?Y ( ) N ( ) PPO? Y ( ) N ( ) Does your insurance require out of network Away from home or Guesting Certification?Y( ) N ( ) THE FOLLOWING AUTHORIZATION MUST BE SIGNED BEFORE WE CAN FILE A CLAIM WITH YOUR HEALTH INSURANCE CARRIER OR THE SECONDARY ATHLETIC INSURANCE CARRIER. I hereby authorize the University of South Alabama Department of Athletics to file a claim on my behalf for the athletic injury/illness sustained by (dependent) under the above group medical policy. I confirm that my medical health insurance provides benefits for claims in the Mobile area. Further I agree and consent that any amounts payable under this policy may be paid to the medical provider. My son/daughter is not covered under my, or their own, personal health insurance. I understand that my son or daughter will not be allowed to participate in intercollegiate athletics without valid medical health insurance. Student athletes that are scholarship and grant- in- aid recipients can apply for funds that may be available through the student athlete opportunity fund for valid health insurance. Applications are available from the sports medicine department. Therefore, I authorize the University of South Alabama, Department of Athletics to inspect or secure copies of case history, lab reports, diagnosis, x- rays, and any other information related to this claim, and I understand that I will incur all financial responsibility for medical claims due to my son or daughter not being covered under a health plan or that my health plan will not be valid in the Mobile, AL area. Signature of Parent/Guardian Signature of student athlete Date signed