Arcadia University Medical Clearance Packet

Transcription

1 Arcadia University Medical Clearance Packet In order to participate in intercollegiate athletics at Arcadia University, every student-athlete must have a YEARLY pre-participation physical completed as well as current health insurance coverage. - Please note the pre-participation physical may not be completed earlier than June 1, o This physical should be completed by the student-athlete s family physician. - It is essential that these forms are completed and returned to the Athletic Training Room no later than Saturday August 1, Late completion of these required documents will delay your ability to participate in ANY team activities. o Packets can be mailed to: Arcadia University Attn: Danielle Duffy, LAT, ATC Athletics - Kuch Center 450 S. Easton Road Glenside, PA Only original paperwork will be accepted. Do not fax documents. Please retain a copy for your records Please complete the following checklist and return all documents to the above address/location. Arcadia University Medical Clearance Packet: You, the student-athlete, are responsible to complete this paperwork packet in its entirety and submit it to the Athletic Training Department. You must complete all required documents and sign the appropriate pages where indicated. The Medical Clearance Packet includes: Insurance Verification (Page 2) Student Consent for Disclosure (HIPAA) (Page 8) Athletic Clearance Form (Page 3) Assumption of Risk (Pages 9-10) Medical History (Pages 4-5) Proof of Insurance (card copy) (Page 1) Concussion Acknowledgement (Page 6) Physician clearance letter (if necessary) ADD/ADHD Documentation (Page 6) Sickle Cell Trait Status (Page 7) First year and transfer students must complete this packet in addition to student health services information required by Arcadia. Student Health Services paperwork can be accessed at: No physical obtained from student health services will be accepted for clearance in the participation of intercollegiate athletics.

2 ARCADIA UNIVERSITY ATHLETIC TRAINING INSURANCE VERIFICATION / EMERGENCY CONTACT LAST NAME FIRST NAME MIDDLE INITIAL DOB SOCIAL SECURITY # \ HOME ADDRESS CITY STATE ZIP CODE CELL PHONE # \ EMERGENCY CONTACT RELATIONSHIP TELEPHONE Male Parent/Guardian Name Employer Employer Address Female Parent/Guardian Name Employer Employer Address Employer s Telephone Cell Phone Employer s Telephone Cell Phone INSURANCE COMPANY ADDRESS TELEPHONE POLICY # GROUP # POLICY HOLDER NAME RELATIONSHIP POLICY HOLDER DOB / / CURRENT MEDICAL CONDITIONS (such as asthma, diabetes, anemia, infections, etc.):. KNOWN ALLERGIES (such as food, medication, latex, pollen, etc.):. CURRENT MEDICATIONS:. Arcadia University Athletic Staff will not be responsible for the loss of eligibility due to a positive drug test resulting from ADD/ADHD medication for failure to submit the proper documentation to the Sports Medicine Staff. Page2

3 ARCADIA UNIVERSITY ATHLETIC CLEARANCE FORM NCAA policies recommend that any student who intends to participate in intercollegiate athletic activities must have on file at the school a record of having passed a complete physical examination upon initial entrance into the school s intercollegiate athletic program. Arcadia University requires their athletes to complete a heart and lung screening and medical history form yearly. In addition to this medical clearance packet, all athletes must also have completed health records on file in the Student Health Services Center prior to participation. Name DOB Sport(s) Year of Participation Height Weight Blood Pressure / Pulse Normal YES/NO Abnormal / Comments Head, Ears, Nose, Throat Eyes Respiratory Cardiovascular Gastrointestinal Genitourinary Metabolic/Endocrine Neurological Skin Psychiatric Musculoskeletal YES/NO Any history of heart murmur? ADD or ADHD? **if yes please provide documentation that murmur is benign **if yes please provide documentation of testing Sickle Cell Trait? **must confirm status and provide documentation Sickle Cell Trait: The NCAA requires that all student-athletes must declare sickle cell trait status. Refer to Medical Clearance Packet for more information. Has Satisfactorily completed the examination to participate in athletics at Arcadia University Has Not satisfactorily completed the examination and is not cleared to participate in athletics at Arcadia University. The following findings should be further evaluated prior to participation clearance: Name of physician or nurse practitioner Signature of physician or nurse practitioner Phone Number Address Fax Number I, the undersigned, certify that the answers to the questions above are correct and true. I also understand that passing the physical exam does not mean that I am physically qualified to engage in athletics, but that the examiner did not find a medical reason to disqualify me. Student-Athlete Signature Page3

4 MEDICAL HISTORY Has a doctor ever denied or restricted your participation in physical activity for any reason? If yes, please explain: Have you been hospitalized or had surgery in the past 12 months? If yes, please explain: --If yes, please provide a note clearing you for unrestricted participation in the intercollegiate sport you are intending to play. Have you ever had or do you currently have any of the following Yes No Yes No Yes No Anemia Nose injury HIV or AIDS Breathing Problems Sickle cell trait Any injuries of the following? Chest pain/tightness Spleen Injury Foot Chronic cough Stomach/GI problem Ankle Diabetes Urinary problems Lower leg Dizziness/Fainting Do You Wear: Knee Dental Problems Glasses or contacts Thigh Ear Injury Allergies Groin Eye Injury Insects Back Frequent Headaches Latex Shoulder Frequent Nose bleeds Medications Neck Hearing difficulty Other allergies Eye Heart Infection Skin conditions such as: Arm Heart murmur Bacterial infection Elbow Heart racing/skipping MRSA Wrist Heat exhaustion Eating disorders such as Fingers Heat stroke Anorexia Are you missing one of these organs? Hernia Bulimia Eye High blood pressure Psychological disorders Kidney Impaired vision Anxiety Lung Mononucleosis Bipolar Spleen Lung problems Depression Teeth Marfan syndrome Schizophrenia Testicles If you marked yes to any of the above, please explain below: Page4

5 Have you ever had a concussion? NEUROLOGICAL INJURIES YES NO ~If answered yes above please list dates: Have you ever had a skull fracture? Have you ever had a loss of consciousness due to a concussion? Have you ever had amnesia due to a concussion? Have you ever had a stroke? Have you ever had a seizure disorder? **if answered yes above provide note from doctor stating cleared to participate in intercollegiate athletics with a seizure disorder** Family History Have any of your relatives had the following? YES NO RELATIONSHIP Sudden Death Before Age 50 Diabetes Heart Disease Stroke High Blood Pressure Cancer Marfan Syndrome Asthma/Allergies Tuberculosis Alcohol/Drug Problem Depression Sickle Cell Disease FEMALE ATHLETES ONLY When was your first menstrual period? When was your last menstrual period? What was the longest time between periods last year? Are you on birth control? If yes, what type? Do you currently see a gynecologist? When was your last pelvic exam? I certify that my Medical History answers are correct and true. Student Athlete Signature Page5

6 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 sign and symptoms of a concussion. What is a concussion? o It is caused by a blow to the head/body o Can be from contact with another player, hitting a hard surface (ground, floor, ice, etc) or being hit by a piece of equipment (ball, bat, lacrosse stick, etc) o Can change the way your brain normally works and presents itself differently for each athlete. o Can occur during practice, competition, or conditioning, in any sport, and at home o Can happen even if you DO NOT lose consciousness How can I decrease risk of a concussion? o Do not initiate contact with you head/helmet. (you can still get a concussion even if you are wearing a helmet) o Avoid striking an opponent in the head Follow rules for safety and the rules of the sport o What are the signs and symptoms of a concussion? o Amnesia, Confusion, Headache, Ringing in the ears, Nausea, Vomiting, Sensitivity to light/noise, feeling in a fog, irritability, slowed reaction time, concentration or memory problems (forgetting plays, facts, meeting times, etc) o *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? o DO NOT HIDE IT! Report it to your athletic trainer and coach. Never ignore a blow to the head o GET CHECKED OUT! Do not return to participation in game, practice, or any other activity. Your athletic trainer will be able to tell you if you have a concussion and have the authority and knowledge to determine when you return to play. The sooner you get checked out, the sooner you may be able to return to play o 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 concussions can cause permanent brain damage or even death. By signing below, I state that I understand this concussion material. I also confirm that I shall always report any suspecting concussion, of myself or others, to the appropriate medical professionals. Student-Athlete Signature Print Student-Athlete Name Sport ADD/ADHD DOCUMENTATION Effective 2009, there is more strict application of the NCAA Medical Exception policy regarding the use of banned stimulant medication prescribed to treat Attention Deficit Hyperactivity Disorder (ADHD). Stimulant medication commonly prescribed to treat ADHD, such as Adderall and Ritalin, are among banned substances for which a medical exception for a positive drug test may be granted, provided that the sports medicine staff presents documentation that those substances have been prescribed by a physician and is supported by a clinical assessment for education or health reasons. Under this stricter application of medical exceptions, written documentation for stimulants prescribed to treat ADHD must include (1) evidence that the student-athlete has undergone a clinical assessment to diagnose the disorder, (2) appropriate documentation supporting the diagnosis, (3) instructions for the proper monitoring for the use of the stimulant medication, (4) name/dosage of prescribed medications, along with any important safety information Are you currently under the care of a physician for this condition? YES NO Page6

7 SICKLE CELL TRAIT STATUS About Sickle Cell Trait: Sickle cell trait is an inherited condition of the oxygen-carrying protein, hemoglobin, in the red blood cells Sickle cell train 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 and Central American ancestry, persons of all races and ancestry may test positive for sickle cell trait Sickle cell trait has been associated with a condition known as exertional rhabdomyolysis, renal failure and death. Complicating factors include extreme exertion, increased heat, altitude and dehydration. Sickle cell trait is usually benign, but during intense, sustained exercise, hypoxia (lack of oxygen) in the muscles may cause sickling of red blood cells (red blood cells changing from 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. Please see the below website for more information regarding sickle cell trait including the NCAA fact sheet. Welfare/Health+and+Safety/SickleCellTrait Sickle Cell Trait Testing: The NCAA requires that all student-athletes, regardless of class, will have to declare sickle cell trait status starting with the school year. The NCAA and Arcadia University recommend that all student-athletes know their sickle cell trait status by undergoing sickle cell trait testing prior to participation in any intercollegiate athletic activity. Sickle Cell Trait testing in the form of a blood test can be done by the student-athlete s personal primary care physician. Student-athletes who are positive for the trait will not be prohibited from participating in intercollegiate athletics. Being aware of the trait and taking proper precautions can help student-athletes enjoy successful and healthy careers. Test Results or Sickle Cell Trait Testing Waiver After reviewing the above information and the NCAA Fact Sheet for Student-Athletes, I have elected to: Attach to this packet, documented proof of my Sickle Cell Trait status. OR Sign Sickle Cell Trait Waiver I, understand and acknowledge that the NCAA and Arcadia University Athletic Department recommends 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 testing. 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 disabilities experienced, I hereby affirm that I have fully disclosed in writing any prior medical history and/or knowledge of sickle cell trait status to the Arcadia University Sports Medicine Staff. I do not wish to undergo sickle cell trait testing and I voluntarily agree to release, discharge, indemnify, and hold harmless Arcadia University, its officers, employees, and agents from any and all costs, liabilities, expenses, claims demands, or cause of action on account of any loss or personal injury that might result from my non-compliance with the recommendation of the NCAA and Arcadia University Athletic Department. I have read and signed this document with full knowledge of its significance. I further state that I am at least 18 years of age and competent to sign this waiver. Student-Athlete Signature: Student-Athlete (Print Name): Parent/Guardian Signature (if under 18 years of age) Parent/Guardian (Print Name) **This information will not be shared with any parties other than Arcadia University Athletics Department Page7

8 Student-Athlete Authorization/Consent For Disclosure of Protected Health Information I hereby authorize the physicians, athletic trainer, sports medicine staff and other health care personnel representing Arcadia University to release information regarding my protected health information and any related information regarding any injury or illness during my training for and participation in intercollegiate athletics. This protected health information may concern my medical status, and related personally identifiable health information. This protected health information may be released to my parents/guardians, other health care providers, hospitals and/or medical clinics and laboratories, athletic coaches, strength and conditioning coaches, academic counselors, athletic and or university administrators, chaplains and/or clergy members, NCAA Injury Surveillance System, sports information staff and members of the media. I hereby authorize medical insurance coordinators, insurance carriers, and hospitals and/or medical clinics to release all necessary medical billing information. This information is only to be released for settlement of medical bills incurred while participating as a student-athlete at Arcadia University. I understand that my authorization/consent for the disclosure of my protected health information is a condition for participation as an intercollegiate athlete for Arcadia University. I understand that my protected health information is protected by federal regulations under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) or the Family Educational Rights and Privacy Act of 1974 (the Buckley Amendment/FERPA) and my not be disclosed without my authorization under HIPAA or my consent under the Buckley Amendment. I understand that once information is disclosed per my authorization/consent, the information is subject to re-disclosure and may no longer be protected by HIPAA and/or the Buckley Amendment. I understand that I may revoke this authorization/consent at any time by notifying the Head Athletic Trainer in writing. If I do, it will not have any effect on actions Arcadia University took in reliance on this authorization/consent prior to receiving the revocation. This authorization/consent expires six (6) years from the date it is signed. Name of Student-Athlete of Birth of Student-Athlete Signature of Student Athlete Signature of Parent/Legal Guardian (if student-athlete is under 18 years of age) Page8

9 ARCADIA UNIVERSITY INTERCOLLEGIATE ATHLETIC PROGRAM RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT IN CONSIDERATION of being permitted to participate in ARCADIA UNIVERSITY s ( ARCADIA ) Intercollegiate Athletic Program ( Program ) I, ( Participant ), (or on behalf of my minor child) hereby acknowledge and agree to the following: INFORMED CONSENT: I have been informed of and I understand the various aspects of the Program. I understand that as a Participant in the Program, I will be engaged in activities that may include, but are not limited to, practicing, training, observing, traveling to and from, and competing in Program events, during which I could sustain serious personal injuries, illness, property damage, or even death as a consequence of not only ARCADIA s actions or inactions, but also the actions, inactions, negligence or fault of others, and that there may be other risks not known to me or not reasonably foreseeable at this time. I further understand and agree that any injury, illness, property damage, disability, or death that I may sustain by any means is my sole responsibility, except for those occurrences due to ARCADIA s gross negligence or intentional acts. RELEASE AND WAIVER OF LIABILITY: I, on behalf of myself, my personal representatives, heirs, executors, administrators, agents, and assigns, HEREBY RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE ARCADIA, its governing board, directors, officers, employees, coaches, athletic trainers, agents, volunteers and any students (hereinafter referred to as Releasees ) for any and all liability, including any and all claims, demands, causes of action (known or unknown), suits or judgments of any and every kind (including attorney s fees), arising from any injury, property damage or death that I may suffer while playing, practicing or in any other way involved in my participation in the Program, REGARDLESS OF WHETHER THE INJURY, DAMAGE OR DEATH IS CAUSED BY THE RELEASEES, UNLESS THE INJURY DAMAGE OR DEATH IS CAUSED BY THE RELEASEES GROSS NEGLIGENCE OR INTENTIONAL ACTS, AND REGARDLESS OF WHETHER THE INJURY DAMAGE OR DEATH OCCURS WHILE IN, ON, UPON, OR IN TRANSIT TO OR FROM THE PREMISES WHERE THE ACTIVITY, OR ANY ADJUNCT TO THE ACTIVITY, OCCURS OR IS BEING CONDUCTED. I further agree that the Releasees are not in any way responsible for any injury or damage that I sustain as a result of my own negligent acts. ASSUMPTION OF RISK: I understand that there are potential dangers incidental to my participation in Program activities, including but not limited to, practicing, training, observing, traveling to and from, and competing in Program events. I understand that there are potential dangers, which may expose me to the risk of personal injuries, property damage, or even death. I am aware that the Program can involve vigorous activity involving severe cardio-vascular stress and/or violent physical contact. I understand that Intercollegiate Athletic activities involve certain risk, including but not limited to, death serious neck and spinal injuries resulting in complete or partial paralysis, brain damages, and serious injury to virtually all bones, joints, muscles, and internal organs, and that protective equipment may be inadequate to prevent serious injury. I further understand that Intercollegiate Athletics involve a particularly high risk of knee, head, and neck injury. In addition, I understand that participation in the Program involves activities incidental thereto, including, but not limited to, travel to and from the site of the Program, participation at sites that may be remote from available medical assistance, and the possible reckless conduct of other participants. Furthermore, I understand that potential risks may arise due to the following: travel to and from ARCADIA via private vehicle, common carrier, and/or an ARCADIA owned vehicle; weather conditions; facility conditions; equipment conditions; negligent first aid operations or procedures of Releasees; and other risks that are unknown at this time. I KNOWINGLY AND VOLUNTARILY ASSUME ALL SUCH RISKS OF PARTICIPATION IN PROGRAM ACTIVITIES, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THE ACTS OF THE RELEASEES, UNLESS THEY ARISE FROM THE RELEASEES INTENTIONAL OR GROSSLY NEGLIGENT ACTS, and assume full responsibility for my participation in the Program. INDEMNITY: I, on behalf of myself, my personal representatives, my heirs, executors, administrators, agents, assigns, agree to hold harmless, defend and indemnify the Releasees from any and all liability, including any and all claims, demands, causes of action (known or unknown), suits, or judgments or any and every kind (including attorneys fees), arising from any injury, property damage or death that I may suffer as a result of my participation in the Program, REGARDLESS OF WHETHER THE INJURY, DAMAGE OR DEATH IS CAUSED BY THE RELEASEES OR OTHERWISE, UNLESS THE INJURY, DAMAGE OR DEATH IS CAUSED BY THE RELEASEES GROSS NEGLIGENCE OR INTENTIONAL ACTS. PERSONAL MEDICAL INSURANCE: I agree to purchase and maintain during the term of the Program personal medical insurance. I further acknowledge that I am responsible for the cost of any and all medical and health services I may require not directly related to my participation in the Program. CERTIFICATION OF FITNESS TO PARTICIPATE: I attest that I am physically and mentally fit to participate in Intercollegiate Athletics and that I do not have any medical record of history that could be aggravated by my participation in my particular sport. Further, I agree to abide by ARCADIA s requirements, rules and decisions for physicals and medical exams for student athletes. Page9

10 MEDICAL CONSENT: I understand and agree that Releasees may not have medical personnel available at the location of the Program. In the event of any medical emergency, I authorize and consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment, and hospital care that ARCADIA personnel deem necessary for my safety and protection. I UNDERSTAND AND AGREE THAT RELEASEES ASSUME NO RESPONSIBILITY FOR ANY INJURY OR DAMAGE WHICH MIGHT ARISE OUT OF OR IN CONNECTION WITH SUCH AUTHORIZED EMERGENCY MEDICAL TREATMENT. CHOICE OF LAW: I hereby agree that this Agreement shall be constructed I accordance with the laws of the Commonwealth of Pennsylvania, without regard to conflict of laws. SEVERABILITY: If any term or provision of this Agreement shall be held illegal, unenforceable, or in conflict with any law governing this Agreement the validity of the remaining portions shall not be affected thereby. I HAVE READ THE ABOVE WAIVER AND RELEASE AND BY SIGNING IT AGREE IT IS MY INTENTION TO EXEMPT AND RELIEVE ARCADIA FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY NEGLIGENCE OF RELEASEES OR OTHERWISE, UNLESS THE INJURY, DAMAGE OR WRONGFUL DEATH IS CAUSED BY THE RELEASEES GROSS NEGLIGENCE OR INTENTIONAL ACTS. : (Signature) (Printed Name of Participant) Signature of Parent/Guardian for Participants Who Are Minors: I certify that I have custody of Participant or am the legal guardian of Participant by court order. I HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND AND AGREE TO ITS TERMS. I AM AWARE THAT THIS AGREEMENT INCLUDES A RELEASE AND WAIVER OF LIABILITY, AN ASSUMPTION OF RISK, AND AN AGREEMENT TO INDEMNIFY ARCADIA. I agree to the foregoing conditions on behalf of my minor child. : (Signature of Parent of Guardian) (Printed Name of Parent or Guardian) Received by: : (Signature) (Printed Name of Institution Official) Page10

11 PROOF OF INSURANCE Student Athlete Name Sport(s) Please place copy of FRONT of Insurance Card Please place copy of BACK of Insurance Card Attention: If your primary insurance carrier changes at any point throughout the year, please provide updated information to the athletic training staff in a timely manner. Page1