Missouri Valley College Sports Medicine Staff

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1 MISSOURI VALLEY COLLEGE SPORTS MEDICINE POLICY AND PROCEDURE Athletes Name: Sport: Please review all of the forms in this packet. Each of the forms contains information important to the student athlete. Please make sure to completely fill out online, if you print and fill out, please make sure to sign and date each form in blue or black ink. Please return forms to MVC Athletic Training Room in Burns Gym or completed forms to If you send them to any other department, there is no guarantee that we will receive them. Please review the forms for completeness. Incomplete forms or information found to be incomplete are unacceptable. Save a copy for your own records if you are sending the original packet. Student athletes will not be allowed to practice or compete until all of the information is provided. MISSOURI VALLEY COLLEGE PARTICIPATION REQUIREMENTS Missouri Valley College requires all student athletes to carry private health care insurance. Student athletes must provide proof of health insurance with Missouri Valley College Athletic Training or he/she WILL NOT be eligible for participation. If a student athlete s health insurance changes throughout the year it is his/her responsibility to inform the Missouri Valley College Athletic Training department of these changes and have a copy of the new insurance information. All participants must also receive a pre-participation physical, prior to ANY sport activity including: weight lifting, conditioning, practices and competition that takes place at any time during preseason, in season or post season. Physicals are good for one calendar year, from date of exam. All physicals must be current and in good standing for the entire school year. Missouri Valley College Sports Medicine Staff Matt Long ATC, LAT Head Athletic Trainer Kasey Currence ATC, LAT Sierra Fultz ATC, LAT Tiffany Webb ATC, LAT Office: Fax: (Attn: Athletic Training) Missouri Valley College Attn: Athletic Training 500 E. College Marshall MO Alex Thompson ATC, LAT ALL PAPERWORK MUST BE COMPLETED AND SUBMITTED BY AUGUST 1st FOR ATHLETE TO BE ELIGBLE FOR PARTICIPATION.

2 MVC INSURANCE NOTIFICATION As the parent/legal guardian/participant, I understand that Missouri Valley College DOES NOT carry health insurance for their student-athletes. Therefore, I realize that ALL medical bills incurred as a result of my son/daughter participating in athletics at MVC are my responsibility. I realize that it is mandatory for my son/daughter to be adequately covered by health insurance while participating in athletics at MVC. This health insurance policy that I have chosen covers my son/daughter for accidents that occur from sports participation (broken bones, torn ligaments, dislocation, etc...). If I cancel or have my medical insurance discontinued for any reason, either voluntarily or involuntarily, I realize that all medical bills that may accumulate are still my responsibility and not the responsibility of MVC or its employees. It is the responsibility of the Parent/Guardian/Participant to determine if the insurance the student-athlete is currently covered under is adequate for athletic participation and will cover the student-athlete in the state of Missouri at Missouri Valley College. Should the insurance not cover athletics or in the state of Missouri all medical bills will be the responsibility of the parent/guardian/participant. The student-athlete must be covered during all participation of any type of sport/team related activity throughout the entire 10 month school year (Aug 1st-May31st). This includes all pre-season, in-season, post-season and off-season activities that take place during the school year and season of the sport. If the student-athlete is not covered during any of this time, they will not be allowed to participate. Any injury incurred will not be the financial responsibility of Missouri Valley College. Signature Field Date: MISSOURI VALLEY COLLEGE DRUG POLICY NOTIFICATION AND ACKNOWLEDGEMENT By signing this form, you certify that you agree to be tested for drugs at any time, for any reason during the academic school year. You agree to allow Missouri Valley College (MVC) to test you for the banned drugs that are listed in the MVC and/or NAIA Banned Drug List. This means that you agree to allow MVC to test on a year round basis for the banned drugs appearing on the MVC and/or NAIA Banned Drug List, this list is in the student-athlete handbook. Additionally, you also agree to be tested for anabolic steroids, elevated levels of HGH, diuretics, urine manipulators, and any drug masking agent. You understand that if you test positive, you will be responsible for the payment of the drug testing fee. If you test negative, the institution/team/sport will assume the cost of the fees. The MVC drug policy can be found in the student athlete handbook on pages Initial I have read and understand the MVC drug policy outlined in the Student Athlete Handbook. Signature

3 MISSOURI VALLEY COLLEGE STUDENT-ATHLETE INSURANCE INFORMATION FORM Please complete All of the following information Student Athlete Information (1) LAST NAME (2) FIRST NAME (3) DATE OF BIRTH (4) SPORT(S) (5) SS # Address Phone number Allergies Other Medical Conditions: (Diabetes, Asthma, Heart condition, sickle cell status, etc.) Medications: Emergency Contact Information (1) LAST NAME (2) FIRST NAME (3) PRIMARY PHONE NUMBER HOME CELL (4) (5) HOME ADDRESS CITY Primary Policy Holder (1) NAME OF INSURANCE COMPANY STATE Insurance Information Primary Policy SS# ZIP (2) GROUP AND/OR POLICY NUMBER (3) IDENTIFICATION NUMBER (4) INSURANCE COMPANY ADDRESS CITY STATE ZIP PLEASE PROVIDE A PHOTOCOPY OF YOUR INSURANCE CARD (front and back) If your insurance coverage for your child changes or terminates during the year, please contact us at telephone with the updated information immediately and/or fax a copy of the new insurance card using fax Affidavit: I verify that the above statement regarding insurance is accurate and complete. Signature: Date:

4 MISSOURI VALLEY COLLEGE RETURNER YEARLY MEDICAL APPRAISAL Todays Date: Academic Year: (ie ) Sport ATHLETE INFORMATION Athlete s Name Freshman Sophomore Junior Senior Student ID Number Address Birth Date Local Address City State Zip Code Permanent Address City State Zip Code Home Phone Number Cell Phone Number IN CASE OF EMERGENCY Name Rela onship Contact Phone Number PERSONAL MEDICAL HISTORY In the past 12 months, have you ever been restricted from par cipa on in physical ac vity? Yes (specify below) No Date Please Specify Do you wear any special protec ve or correc ve equipment or devices to par cipate in your sport? (ie braces, ortho cs, etc) Device Device Please Specify Please Specify Are you currently taking any PRESCRIBED or OVER THE COUNTER medica ons? (please include birth control, insulin, allergy shots/ pills, asthma inhaler, an depressants, an inflammatory including aspirin, or medica ons for ADD/ADHS) Name Dosage How many mes daily/weekly Reason Since beginning eligibility as a student athlete at Missouri Valley, have you had any: Serious Illness, Disease, Infec on Orthopedic Injury Opera on and/or Hospitaliza on Mental Illness Accident (non sport related) Have you been examined by a physician other than a Missouri Valley team physician in the past 12 months? If yes, please specify Have you been outside of the United States in the past 12 months? If yes, please specify Have you had any immediate rela ve die suddenly in the past 12 months? If yes, please specify In the past year, have you experienced dizziness, light headedness, passing out or fain ng, chest pain, discomfort, ghtness in chest, difficulty breathing more than usual, or wheezing before/a er exercise? If so, please specify In the past year have you experienced an injury to the head/neck? If so, please specify Have you had a significant weight loss or weight gain in the past year? If so, please specify

5 MISSOURI VALLEY COLLEGE RETURNER YEARLY MEDICAL APPRAISAL ORTHOPEDIC YEARLY APPRASIAL PLEASE INDICATE IF YOU HAVE SUSTAINED ANY INJURIES TO SAID BODY PARTS IN THE PAST 12 MONTHS HEAD Yes No Right Le Please specify NECK Yes No Right Le Please specify SHOULDER Yes No Right Le Please specify ARM Yes No Right Le Please specify ELBOW Yes No Right Le Please specify FOREARM n Yes No Right Le Please specify WRIST Yes No Right Le Please specify HAND Yes No Right Le Please specify FINGERS Yes No Right Le Please specify CHEST Yes No Right Le Please specify SPINE Yes No Right Le Please specify ABDOMEN Yes No Right Le Please specify PELVIS Yes No Right Le Please specify HIP Yes No Right Le Please specify THIGH Yes No Right Le Please specify KNEE Yes No Right Le Please specify LEG Yes No Right Le Please specify ANKLE Yes No Right Le Please specify FOOT Yes No Right Le Please specify TOES Yes No Right Le Please specify IF YOU HAVE ANY ADDITIONAL CONDITIONS, PROBLEMS OR COMMENTS THAT HAVE NOT BEEN ADDRESSED THOROUGHLY IN THE ABOVE QUESTIONAIRE, PLEASE USE THE SPACE BELOW TO INFORM US SO THAT WE MAY BE ABLE TO BETTER SERVE YOU WITH OUR MEDICAL CARE. I,, DO/ DO NOT (please circle one) wish to see a team physician in addi on going over this form with a cer fied athle c trainer. Printed Name ATC Printed Name Pa ent Signature ATC Signature Date

6 MISSOURI VALLEY COLLEGE ASSUMPTION OF RISK STATEMENT I,, am aware that playing and/or practicing in any sport can be a dangerous activity involving MANY RISKS OF INJURY. I understand that the dangers and risks of playing and or practicing in any sport include, but are not limited to, death, serious head, neck, and spinal injuries which may result in complete or partial paralysis or brain damage, 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 own (or my son/daughter) body, general health or well-being. Because of the dangers of participation in any sport, I recognize the importance of following the coach's instructions regarding playing techniques, training rules of the sport, other team rules, and to obey such instructions. All participants have the responsibility to help reduce the chance of injury by executing proper skill techniques of sport. Therefore, all student-athletes must obey all safety rules and regulations, report all physical problems to the athletic trainer and/or coach, follow a proper conditioning program, and inspect personal protective equipment daily. AFTER READING/PRINTING FORM PLEASE INITIAL EACH OF THE FOLLOWING STATEMENTS TO SHOW THAT THE STATEMENT HAS BEEN READ, UNDERSTOOD, AND APPROVED. I consent to have my self/son/daughter represent the Missouri Valley College in approved activities except those activities excluded by the examining team physicians. In the event of any injury or illness, including an emergency situation, requiring medical attention, I grant permission for any treatment deemed necessary by the Sports Medicine Staff or attending physician and also authorize transfer of my self/son/daughter to a qualified medical facility. I agree not to hold the Missouri Valley College or anyone on its behalf responsible for any injury occurring to my self/son/daughter in the proper course of such athletic activities or travel. I acknowledge and accept that there are risks of physical injury involved in athletic participation which may result in permanent paralysis, mental disability, and death. I hereby voluntarily assume all risks associated with participation and agree to exonerate and save harmless Missouri Valley College and their agents, servants, and employees, the athletic staff of Missouri Valley College, the physicians and other practitioners of the healing arts treating my self/son/daughter from any and all liability claims, causes of action or demands of any kind and nature whatsoever which may arise by, or in connection with, my participation in any activities to the Missouri Valley College team in which my self/son/daughter is involved. Signature of Student-Athlete Signature of Parent/Legal Guardian (if student-athlete is under 18 years of age)

7 AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION I hereby release of my medical information to the following (check all that apply): (Type name in space provided) - Parents/Legal Guardians/ Spouse - Coaches/Athletic Staff -Teammates -Media -Professional teams and their representatives -MVC Student Athletic Trainers (All have signed confidentiality agreements) -HAAC/NAIA -MVC Medical Facilities (Counseling Center, Student Health Center) I hereby authorize all members of the Missouri Valley Sports Medicine Staff, all Missouri Valley College Team Physicians, or any other physicians or health care professionals retained by them to release information, records, and reports regarding my medical history, medical status, record of injury and/or surgery, prognosis, diagnosis, record of serious illness, rehabilitation, and related personally identifiable health information to parties identified above. The information includes injuries or illnesses relevant to past, present, or future participation in athletics at Missouri Valley College. I understand that if the information being disclosed herein contains information regarding Athletic Department drug testing and or drug/alcohol abuse or treatment, psychiatric care, sexually transmitted diseases, AIDS or HIV, or Hepatitis B or C testing or results, I agree to their release. The reason for this disclosure is to advise the parties identified above of the nature, diagnosis, prognosis, or other treatment concerning my medical condition and injuries/illnesses sustained while I am a student-athlete. I understand that the individuals or entities receiving the information are not health care providers or health plans covered by federal privacy regulations, and that the information described above may be redisclosed publicly. I understand that Missouri Valley College will not receive compensation for its use/disclosure of the information. I may inspect or copy any information used/disclosed under this authorization and I am entitled to receive a copy of this authorization. I understand that I may revoke this authorization at any time by notifying in writing to the Head Athletic Trainer, but if I do, it will not have any effect on actions the university took in reliance on this authorization prior to receiving the revocation. This authorization expires six (6) years from the date it is signed. I have agreed to submit this application by electronic means. By signing this application electronically, I certify that my answers are correct and complete to the best of my knowledge. By initialing this box and typing my name below, I am electronically signing my application. Signature of Student-Athlete Signature of Parent/Legal Guardian (if student-athlete is under 18 years of age) Submit by

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