Dear Parent/Guardian,

Transcription

1 Dear Parent/Guardian, On behalf of the Saint Joseph s College Sports Medicine Department welcome back, we are very excited to have your son/daughter as a student-athlete at Saint Joseph s College for the upcoming year. Our goal is to provide our student-athletes with the best possible athletic healthcare. This healthcare includes prevention, evaluation, treatment, and rehabilitation of athletic injuries and illnesses sustained during practices and games. Saint Joseph s College has a partnership with Jasper County Hospital to provide athletic training services and Unity Orthopedics to provide physician coverage. Please read this letter in its entirety and retain it for future reference as it explains our policies regarding the health care of studentathletes. In this packet you will find pertinent information regarding our medical and insurance coverage for the student-athletes. In this information you will find the proper procedure for reporting athletic-related injuries, medical bill payment procedure and policy, and NCAA education on Sickle Cell Trait, concussions, and banned substances. At this time please make sure that you read and fully understand the athletic injury, illness, and medical policies and procedures of the Saint Joseph s College Athletic Training Program. If at any time you have questions regarding these policies and procedures please contact me at mwillett@saintjoe.edu. The following forms must be filled out completely and mailed to Saint Joseph s College, ATTN: Matthew Willett, P.O. Box 875, Rensselaer, IN no later than August 1 st. A checklist of forms required by SJC Sports Medicine Staff has been included for your convenience. Please read and understand the Medical Bill Payment Policies and Procedures. If your child sustains an injury during the year that results in a medical bill, please refer back to the policy for pertinent information. It is you and your child s responsibility to ensure the proper procedures are completed in order to avoid any delays on medical bill payments which could result in you being taken to collections. Please fill out all forms in their entirety. These forms are very important for us to maintain accurate medical records for your son/daughter. If at any time the student-athlete was treated at home for an injury or illness, please ensure that we receive documentation from the treating physician on any prescribed prescriptions, physical therapy notes, doctor dictations of the diagnosis, and any restrictions (if any) to their ability to compete in the student-athletes sport. Thank you for your attention to these details. Feel free to contact me at (219) or at mwillett@saintjoe.edu if you have any questions, or troubles downloading and filling out the forms. Sincerely, Matthew Willett, MA, LAT, ATC Head Athletic Trainer

2 Saint Joseph s College Athletic Injury, Illness and Medical Procedures I. Pre-Participation Procedures a. Health Records: It is a Saint Joseph s College requirement that all student athletes must have a completed Health Record on file in the Student Health Center. The school physical form should have been sent to all new students (freshman and transfer) or may be obtained from the Health Center. All prospective student athletes MUST have returned a completed Health Record to the student Health Center by August 1 st for the fall semester and January 2 nd for new spring semester students. NO student will be allowed to participate in any Saint Joseph s College activity until the Health Record has been accepted. Once a Health Record is submitted and accepted, this requirement will be met for the student s entire undergraduate career at Saint Joseph s College. b. Immunizations: It is Saint Joseph s policy that ALL students show proof that they have met the requirements for current immunization standards. Questions in this area should be referred to Sharon Moore R.N. (Nurse & Wellness coordinator) at the student health center (219) c. Athletic Medical History Folder: Prospective student-athletes must complete a Medical History folder prior to receiving the athletic physical exam. This folder will be completed at the scheduled orthopedic evaluation time. Care must be given to answer all of the questions in the folder completely and accurately. i. Please note: It is important to submit ALL medical records requested, to avoid any delay in the eligibility process for team participation. d. Athletic Insurance Information Form: Saint Joseph s College provides supplemental athletic accident insurance to all sponsored varsity and junior varsity athletes in the event of injury during supervised practice, competition or conditioning sessions. Prospective studentathletes MUST have a completed Athletic Insurance Information form on file with the Athletic Training Office prior to any participation in team activities. This form should be returned to the Athletic Training Office by August 1. Please complete all requested information in its entirety to avoid any delay in the eligibility process. i. Please note: Each student-athlete is responsible for updating his or her Athletic Insurance Information and Medical History Folder. Failure to do so will result in the student incurring any unnecessary medical costs should the incorrect procedures be followed. e. Policy for Pre-Participation Physical Evaluations: ALL persons wishing to participate in intercollegiate athletics at Saint Joseph s College must have a completed school physical form on file in the College Health Center. For athlete s, their athletic pre-participation physical will cover this requirement. Student-athletes should check with their Head Coach as to the date and time of their pre-participation physical exam. Failure to show for an assigned preparticipation physical exam will result in the student having to pay for a physical arranged by the Athletic Training Office with the team orthopedic physician. Reasonable excuses for inability to attend scheduled appointment should be communicated to the Head Certified Athletic Trainer BEFORE the scheduled date and time. i. Students may find themselves placed on a Provisional status after their physical exam. This means that some additional information, testing, or monitoring of the student-athlete is required in order for team participation. Students may play or practice with the team as long as they comply with the restrictions or recommendations of the Athletic Training Staff. ii. Failure to meet deadlines or cooperate with the Athletic Training Staff while on Provisional status will result in the student-athlete being placed on HOLD, thus making the student medically ineligible to participate in ANY SJC athletic activity. Students placed on HOLD status following the physical exam will require further evaluation and possible testing by the Athletic Training Staff for any problem(s) that may inhibit full participation. Students placed on HOLD statues as a result of the physical exam may NOT play or practice with the team until specific tests or

3 II. necessary information is obtained. Students who Fail the physical exam may not participate in ANY SJC sport. Athletic-Related Injury or Illness a. Reporting Procedures: The student-athlete is responsible to report to the Certified Athletic Trainers all injuries and illnesses as soon as possible. The Athletic Training Staff will make ALL of the necessary medical referrals as indicated. In the event of an emergency due to an athletic injury or illness, the athlete will be transported to a prearranged hospital or medical facility. The athlete should at NO time seek outside medical attention for an athletic-related injury or illness without prior written authorization from the Head Certified Athletic Trainer, unless the injury results in a medical emergency. i. Failure to follow these procedures will cause the student-athlete to be placed on HOLD status until ALL related medical records/documentation are received and reviewed by the Athletic Training Office. b. Referrals to Off-Campus Physicians or Medical Specialist: All student-athlete off-campus medical referrals MUST have prior authorization from the SJC Team Physician and the Head Certified Athletic Trainer. The appropriate referral forms MUST be completed by the Health Care Provider and returned to the Athletic Training Office for review before clearance for participation will be given. In case of a Managed Care Insurance Policy (HMO/PPO), the student athlete will be required to follow their primary insurance policy s specific referral procedures. i. All medical tests, treatments and/or procedures rendered by Off-Campus Physician(s) or Medical Specialist(s), other than those approved and performed during the initial visit, MUST again have prior written approval by SJC s Team Physician and the Head Certified Athletic Trainer. All surgical treatments by Non-SJC affiliated Physician(s) MUST have prior written approval by SJC s Team Physician and the Head Athletic Trainer. Saint Joseph s College shall not be responsible for any charges incurred due to the examination, tests, treatments, and/or surgeries by physicians, consultants, and/or hospitals if these procedures are not followed. c. Treatment/Rehabilitation: The athletic training room hours are posted with each sport season. Treatment/Rehabilitation and taping will be available to all athletes, but those in-season sports will receive first priority. Failure of an injured athlete to keep treatment and/or rehabilitation appointments will be interpreted as the athlete s unwillingness to cooperate with the Athletic Training staff for the earliest possible return to competition and may result with the student-athlete being placed on HOLD status making them ineligible to participate in any SJC athletic activity. The Head Coach will be informed of athletes who fail to keep appointments. The Athletic Training Staff receives its direction and supervision from the Team Physician and Director of Athletics. ALL ATHLETES are required to adhere to the Athletic Training Room Rules that are posted. The Athletic Training Room is coeducation and is located in the Scharf Field House. d. Student Health Center: The Johnson Health Center is available to student-athletes with general health concerns or who may require routine nursing care. The services of the Saint Joseph s College nurse carry no charge. Health Center Hours are currently scheduled to be 9:00 a.m. - 12:00 p.m. & 1:00 p.m. - 4:00 p.m. Monday - Friday by appointment. Athletes who are feeling ill are encouraged to inform a Certified Athletic Trainer or go to the Health Center as early as possible to avoid any increase in symptoms, which may prevent them from participating in a practice or game. Student-Athletes who need medical attention beyond that provided by the Saint Joseph s College Nurse will be referred to area physicians or Jasper County Hospital. Medical care is expensive and it is imperative student-athletes have medical insurance to defray these costs. i. When reporting to the Student Health Center or any other medical facility, it is important to identify yourself as an athlete. The RN at the Student Health Center will notify a Certified Athletic Trainer in case there may be a question of ability to practice or play.

4 III. IV. e. Practice or Game Participation for an Injured or Ill Athlete: Decisions on the ability of an athlete to participate in practice or in a game shall be the sole responsibility of the Saint Joseph s College Athletic Training staff and the Team Physician. Non-Athletic Related Injury or Illness a. Reporting Procedures: Injuries or illnesses sustained outside of SJC Athletics MUST be reported to the Athletic Training Office at the student s earliest convenience. If the student desires, The Athletic Training Staff will make ANY of the necessary medical referrals as indicated. If the student chooses to be seen by someone other than the Athletic Training Staff or the Student Health Center they MUST provide the Athletic Training Office with written documentation regarding the condition prior to return to athletic activity. This may be done by obtaining a referral form from the Athletic Training Office or by bringing a written note from the attending Physician. The final decision as to whether a student-athlete may participate in any varsity or junior varsity sport activity rests with the Saint Joseph s College Team Physician. b. Out of Season Injury: Saint Joseph s College shall NOT assume responsibility for care of injuries incurred when the student-athlete is not engaged in formal, official game or practice during an NCAA allowable season. Intercollegiate Athletic Accident Insurance Coverage The Athletic Department at Saint Joseph s College has acquired medical insurance for your son/daughter s protection in the event of an injury during a supervised practice or competition. The insurance policy at Saint Joseph s provides Secondary Coverage FOR INJURIES THAT OCCUR WHILE THE ATHLETE IS PARTICIPATING IN INTERCOLLEGIATE ATHLETICS. This means that all medical bills incurred are initially your responsibility and must be filed with your insurance carrier first. The athletic insurance policy is subject to the following limitations: 1. Only injuries sustained during a game or supervised practice will be covered. 2. The coverage is limited to bills that are incurred within two years from the date of injury. 3. In the event that there is an injury that is the result of a pre-existing condition, Saint Joseph s College will not be responsible for payment of any medical bills related to any previous injury or condition. 4. The Athletic Department is prohibited by NCAA regulations to pay for any illness or injury that may occur outside of athletic participation. 5. Saint Joseph s College and its insurance carrier will only be responsible for medical services performed by Saint Joseph s College medical personnel. All medical visits must be referred through the athletic training staff or Saint Joseph s College team physicians in order for Saint Joseph s College to provide secondary coverage. No outside referrals, consultations, or services will be covered by Saint Joseph s College without prior authorization by the Saint Joseph s College medical staff. 6. If at any time the medical insurance that the student athlete is covered under changes, it is the responsibility of the student athlete and/or their parents to provide new documentation (i.e. new insurance card) of medical insurance changes to the SJC athletic training department. All medical bills that are the result of an injury due to participation in intercollegiate athletics will be in the athlete s name and will be sent directly to them or to their home address. In some cases, the Athletic Department may get a copy of the bill but in no case will the Athletic Department be the primary place for the incurred to be sent. Once you receive the bill, you will need to submit it to your insurance carrier. They will either honor the claim and pay all or a portion of the bill or send you a letter of denial. If there is a balance remaining after submitting the bill to your primary insurance, send a copy of the explanation of benefits (EOB) from the insurance company and an itemized copy of the bill to the Saint Joseph s College Athletic Department, Attn: Linda Deno, PO Box 875, Rensselaer, IN These procedures need to be followed; our insurance

5 company will not be able to make payment on any bills until they have gone through your insurance carrier first. Parents and student-athletes have the right to choose and utilize medical professionals other than those associated with Saint Joseph s College. If you choose to have a second opinion, Saint Joseph s College is not financially responsible for ANY expenses incurred in connection with the second opinion. It is the student athlete s responsibility to submit to Saint Joseph s College all medical records associated with the second opinion. Please Note: If the primary family coverage is through HMO (Health Maintenance Organization) or PPO (Preferred Provider Organization) you must follow the proper procedures required by your plan in order for the college s insurance to satisfactorily complete its portion of the claim. This is especially important if your plan requires preauthorization to have your son/daughter treated if we are out of your plan s service area. An out of network provider option may enable your son/daughter to be seen by the team physician and expedite his/her return to activity. **Saint Joseph s College will not be responsible for the payment of any medical bills if the above procedures are not followed. This includes the student-athlete s failure to follow their personal primary medical health insurance procedures for filing a claim. Any questions about a claim should be referred to the Athletic Training Office without delay at (219)

6 Documentation Check List: (Freshman/New Transfer Student Athlete) Please fill out all forms completely and to the best of your knowledge. Failure to do so may delay the student athlete s ability to participate in intercollegiate athletics at Saint Joseph s College. Emergency Contact/Insurance Form Front and back copy of insurance card Signed Acknowledgement of Medical Policies Signed Assumption of risk and consent to treat form Signed Returning Athlete History Questionnaire Sickle Cell Trait Solubility Test Results or Newborn screening for sickle cell trait ADD/ADHD exemption form (If necessary) Concussion Fact Sheet

7 Documentation for ADD/ADHD Medical Exceptions Dear Parent The NCAA has mandated that member institutions provide appropriate documentation to support the legitimacy of ADD/ADHD medications prescribed to their athletes. Annual NCAA drug testing will produce a positive result with ADD/ADHD medications used by athletes. Therefore documentation will provide proof of legitimate use. In response to this, Saint Joseph s College Sports Medicine Department requests that you submit a letter, on official physician office letterhead, from the prescribing physician that contains the following information: Student athlete name Student athlete date of birth Date of clinical evaluation Clinical evaluation components Physician name (printed) Physician, office address, and phone number Physician specialty Physician signature and date The letter will be kept in your athlete s medical file, in the athletic training room, for reference by the NCAA if needed. In the event of a positive drug test, this letter will be used to confirm the legitimate medicinal use of the prescribed ADD/ADHD medication. Please send the letter to the following address: Matthew Willett, Head Athletic Trainer, Saint Joseph s College, P.O. Box 875, Rensselaer, IN Please feel free to contact the Athletic Training Office at with any questions. Thank you Matthew Willett, MA, LAT, ATC Head Athletic Trainer Saint Joseph s College

8 NCAA Banned Drugs It is your responsibility to check with the appropriate or designated athletics staff before using any substance The NCAA bans the following classes of drugs: Stimulants Anabolic Agents Alcohol and Beta Blockers (banned for rifle only) Diuretics and Other Masking Agents Street Drugs Peptide Hormones and Analogues Anti-estrogens Beta-2 Agonists Note: Any substance chemically related to these classes is also banned. The institution and the student-athlete shall be held accountable for all drugs within the banned drug class regardless of whether they have been specifically identified. Drugs and Procedures Subject to Restrictions: Blood Doping. Local Anesthetics (under some conditions). Manipulation of Urine Samples. Beta-2 Agonists permitted only by prescription and inhalation. Caffeine if concentrations in urine exceed 15 micrograms/ml. NCAA Nutritional/Dietary Supplements Warning: Before consuming any nutritional/dietary supplement product, review the product with the appropriate or designated athletics department staff! Dietary supplements, including vitamins and minerals, are not well regulated and may cause a positive drug test result. Student-athletes have tested positive and lost their eligibility using dietary supplements. Many dietary supplements are contaminated with banned drugs not listed on the label. Any product containing a dietary supplement ingredient is taken at your own risk.

9 Note to Student-Athletes: There is no complete list of banned substances. Do not rely on this list to rule out any supplement ingredient. Check with your athletics department staff prior to using a supplement. Some Examples of NCAA Banned Substances in Each Drug Class Stimulants: amphetamine (Adderall); caffeine (guarana); cocaine; ephedrine; fenfluramine (Fen); methamphetamine; methylphenidate (Ritalin); phentermine (Phen); synephrine (bitter orange); methylhexaneamine, bath salts (mephedrone) etc. exceptions: phenylephrine and pseudoephedrine are not banned. Anabolic Agents (sometimes listed as a chemical formula, such as 3,6,17-androstenetrione): Androstenedione; boldenone; clenbuterol; DHEA (7-Keto); epi-trenbolone; etiocholanolone; methasterone; methandienone; nandrolone; norandrostenedione; ostarine, stanozolol; stenbolone; testosterone; trenbolone; etc. Alcohol and Beta Blockers (banned for rifle only): alcohol; atenolol; metoprolol; nadolol; pindolol; propranolol; timolol; etc. Diuretics (water pills) and Other Masking Agents: bumetanide; chlorothiazide; furosemide; hydrochlorothiazide; probenecid; spironolactone (canrenone); triameterene; trichlormethiazide; etc. Street Drugs: heroin; marijuana; tetrahydrocannabinol (THC); synthetic cannabinoids (e.g., spice, K2, JWH-018, JWH- 073) Peptide Hormones and Analogues: growth hormone(hgh); human chorionic gonadotropin (hcg); erythropoietin (EPO); etc. Anti-Estrogens : anastrozole; tamoxifen; formestane; ATD, clomiphene etc. Beta-2 Agonists: bambuterol; formoterol; salbutamol; salmeterol; etc. Additional examples of banned drugs can be found at Any substance that is chemically related to the class, even if it is not listed as an example, is also banned! Information about ingredients in medications and nutritional/dietary supplements can be obtained by contacting the Resource Exchange Center (REC), or password ncaa1, ncaa2 or ncaa3. It is your responsibility to check with the appropriate or designated athletics staff before using any substance.

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11 Saint Joseph s College Sickle Cell Testing Policy As of August 2012 the NCAA has established a rule for sickle cell trait testing in all Division II studentathletes. All student-athletes must be either tested for sickle cell trait, provide documented results of a prior sickle cell solubility test, or sign a waiver declining to be tested before they are allowed to participate in intercollegiate athletics. In order to be cleared for participation at Saint Joseph s College, studentathletes must satisfy one of the following options. 1) Provide results of a prior sickle cell solubility test. Most states have newborn screening programs to identify sickle cell trait status at birth. Studentathletes may contact their pediatrician/family physician, or birth hospital to find out if they have sickle cell trait results on file. Student-athlete may request a written copy of the results and send them to the SJC sports medicine staff with the rest of their medical paperwork. *Student-athletes may also inquire with their state s department of health about obtaining newborn screening results. Indiana State Department of Health (317) , Illinois Department of Public Health (217) ) Obtain Sickle Cell solubility test for sickle cell trait If student-athletes were not tested of cannot provide results of a previous test at birth, they may be tested through their own physician. **The NCAA has signed an agreement with Quest Labs for access to an affordable exam ($32.50). You may request a sickle cell test by ordering a test through Quest Labs. Step 1: Go to website Step 2: Register for the Sickle Cell Screening Test (Cost is $32.50, may be paid online with credit or debit card). Step 3: The student-athlete will be able to determine the most convenient Quest Diagnostics Patient Service Center for their blood draw by performing a search on the Medivo website as they are generating the test order. (Put in your zip code a list of Quest Diagnostics nearest your address will be shown.) Step 4: Medivo will give you a confirmation number. Write it down! Your last name and confirmation number are your Medivo website login. CONFIRMATION NUMBER: PRINT YOUR RECEIPT! Step 5: Medivo will you when your TEST REQUISITION IS READY. PRINT YOUR TEST REQUISITION AND TAKE IT TO THE QUEST DIAGNOSTICS YOU SELECTED IN STEP 3. Quest Diagnostics will complete your blood draw and send the results to the Medivo website. Step 6: Medivo will send you an when your results are in (usually takes about 48-hours). Log-in (last name and confirmation code), save your results (PDF form) AND print a copy of your results. Step 7: Submit Sickle Cell Trait Testing Results with your other medical forms or fax (no cover page) to: (219) ) Sign Institutional Waiver (upon request only) If the student athlete is unable to obtain sickle cell trait test results in the manners listed above, they may request to sign an institutional waiver that declines submission of prior test results and sickle cell solubility testing. If the student-athlete does not submit test results from a previous sickle cell solubility test and declines to take the test, they must sign the SJC Sickle Cell Trait Testing Waiver annually. A parent or guardian must sign the waiver if the student athlete is under the age of 18.

12 Name: Sport: Date: MEDICAL POLICY We have received and read a copy of the Saint Joseph s College Department of Intercollegiate Athletics medical policy and insurance coverage information. We understand and pledge that these policies and procedures will be followed while our son/daughter is a member of a Saint Joseph s College athletic team. Athlete Signature: Date: Parent/Guardian Signature: Date: WAIVER OF RISK/LIABILTY By its nature, participation in intercollegiate athletics includes a risk of injury which may range in severity from minor to long term catastrophic, including permanent paralysis to death. Although serious injuries are not common in supervised intercollegiate athletic activities, it is possible to minimize, not eliminate the risk. Use of special protective equipment may be required or recommended for your sport. Be advised that there is not one piece of equipment that is guaranteed to completely protect you from all injuries. Do not alter or use equipment in a manor not approved by its manufacturer. By signing this form, you acknowledge that you have read and understand the risks associated with participation in intercollegiate athletics at Saint Joseph s College. Furthermore, I release and agree to indemnify and hold harmless Saint Joseph s College, its board of trustees, president, officers, students, and employees from all claims, actions, damages, and liabilities for personal injury or damage I might experience relating to or arising out of any intercollegiate athletics activity. Athlete Signature: Date: Parent/Guardian Signature: Date: PERMISSION FOR TREATMENT I hereby give permission to the Saint Joseph s College Athletic Department and Health care providers (Athletic Trainers, team physicians, and other medical personnel) for the prompt treatment of my son/daughter in the event of serious illness, major surgery, or significant accidental injury. I hereby further consent to Saint Joseph s College obtaining whatever medical treatment and/or care as is deemed necessary by University staff for my health and well-being as a student-athlete. Athlete Signature: Date: Parent/Guardian Signature: Date:

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14 Student-Athlete Concussion Statement I understand that it is my responsibility to report all injuries and illnesses to my athletic trainer and/or team physician. I have read and understand the NCAA Concussion Fact Sheet. After reading the NCAA Concussion fact sheet, I am aware of the following information: A concussion is a brain injury, which I am responsible for reporting to my team Initial physician or athletic trainer. A concussion can affect my ability to perform everyday activities, and affect reaction Initial time, balance, sleep, and classroom performance. You cannot see a concussion, but you might notice some of the symptoms right away. Initial Other symptoms can show up hours or days after the injury. If I suspect a teammate has a concussion, I am responsible for reporting the injury to Initial my team physician or athletic trainer. I will not return to play in a game or practice if I have received a blow to the head or Initial body that results in concussion-related symptoms. Following concussion the brain needs time to heal. You are much more likely to have a Initial repeat concussion if you return to play before your symptoms resolve. In rare cases, repeat concussions can cause permanent brain damage, and even death. Initial Signature of Student-Athlete Date Printed name of Student-Athlete

15 Saint Joseph's College EMERGENCY / INSURANCE INFORMATION FORM To Be Used For Emergency Contact and Filing Medical Claims Sport: Athlete Name: Social Security # Date of Birth: College Dorm: Rm:# College Ext: Cell: Home Phone: Home Address: Street City State Zip Medical Alerts Parents Information Please print clearly, or type all information requested. Do not leave any lines blank. This information is very important. Father s Full Name Home Phone: Cell Phone: Address City State Zip Social Security # - - DOB Medical Insurance Co. Primary or Secondary (please Circle) Phone No. Address City State Zip Policy #. Employer Work Phone Address City State Zip Mother s Full Name Home Phone: Cell Phone: Address City State Zip Social Security # - - DOB Medical Insurance Co. Primary or Secondary (please Circle) Phone No. Address City State Zip Policy #. Employer Work Phone Address City State Zip Emergency Contact: (if parent(s) cannot be reached) Name: Phone: Relationship: Is the company or listed plan considered a Health Maintenance Organization (HMO) or a Preferred Provider Organization PPO? Is your daughter/son covered at this time by your present surgical & hospital insurance policy? Does your insurance require a second medical/doctor s opinion? Does your insurance require pre-authorization admission for hospital admission? if yes, phone number Parent & Athlete: I hereby authorize Saint Joseph's College and its excess insurance company to inspect or secure copies of case history records, laboratory reports, diagnosis, x-rays, and any other data covering this and/or previous confinements and/or possibilities. A photo static copy of this authorization shall be deemed as effective and valid as the original. X PARENT S SIGNATURE X ATHLETE S SIGNATURE Parents & Athlete: This form must be completed and returned to the following address before the student-athlete can practice or compete. Parents & Athlete: Saint Joseph's College, Athletic Training Room, P.O. Box 875, Rensselaer, IN I acknowledge receiving one copy of SJC s Athletic Injury & Medical Policy. I understand the College s responsibility and limits to a student who becomes injured as a result of participation in the intercollegiate sport. X X PARENT S SIGNATURE DATE ATHLETE S SIGNATURE DATE IMPORTANT NOTICE: Please attach a copy of your insurance card (front & back) along with Prescription card if separate.

16 Saint Joseph's College Athletic Training Returning Medical Update Name: Sport: All answers pertain to the period of time from August 1 of last year and the summer break of the same year. Please explain YES answers in the space provided. If evaluated for an injury or illness by a physician outside of the SJC team physicians, please provide doctors notes, ant restrictions of activity, and a release to activity. YES NO 1. Have you experienced a CONCUSSION or INJURY to the HEAD since last season? YES NO 2. Have you experienced any JOINT or LIMB injury and/or pain since last season? YES NO 3. Have you had any X-RAYS, DIAGNOSTIC TESTING, or DENTAL WORK since last season? YES NO 4. Have you had any SURGERY or ILLNESS of any type since last season? YES NO 5. Have you been HOSPITALIZED or UNDER A PHYSICIAN S CARE? YES NO 6. Do you have any NEW HEALTH CONDITIONS or HEALTH CONCERNS since you last participated in your sport? (e.g. high blood pressure, heart-related problems, shortness of breath, asthma, diabetes) YES NO 7. Do you have any ALLERGIES or take any MEDICATIONS or SUPPLEMENTS? YES NO 8. Have you FELT DIZZY, PASSED OUT, HAD CHEST PAIN, or experienced RACING OR SKIPPED HEART BEATS in the last year? YES NO 9. Have you been fitted for CONTACTS or GLASSES since you last played? (circle which) YES YES NO 10. Do you have any CURRENT SKIN PROBLEMS or ASTHMA (what medications if so)? NO 11. Do you know of any health reasons you should not participate in athletics at SJC? Please sign below to certify that the above information is current and accurate. Athlete Signature: Athletic Trainer: Date: Date: