Student-Athlete Insurance Information Form PLEASE INCLUDE A COPY OF YOUR INSURANCE CARD (BOTH SIDES)

Transcription

1 Student-Athlete Insurance Information Form PLEASE INCLUDE A COPY OF YOUR INSURANCE CARD (BOTH SIDES) PLEASE PRINT ALL INFORMATION CLEARLY AND COMPLETELY! Student-Athlete s Name: SS# - - DOB / /19 (mm/dd/year) HOLY FAMILY UNIVERSITY ATHLETIC INSURANCE POLICY All Holy Family University student-athletes must be covered by a primary health insurance that covers intercollegiate athletics. Holy Family University carries secondary coverage for student-athletes, which covers expenses not covered by the student-athletes primary health insurance when injured during athletics participation. Primary insurance covers the cost of the injury first. Secondary insurance (Holy Family University s coverage) does not cover deductibles or co-pays of the primary insurance. Secondary insurance only covers the excess (remainder) of the costs not covered by the primary insurance. It is recommended that all student-athletes be covered by accidental dental insurance* for dental problems resulting from an accident such as injuries resulting from athletic competition. This is frequently included with your health insurance plan. For student-athletes that are not covered by accidental dental insurance, it is MANDATORY that he or she wear a mouth guard for all practices and games. Failure to do so will place the responsibility of complete payment for resulting injuries on the student-athlete and/or his or her parents/guardians. For student-athletes that are covered by a dental insurance, it is HIGHLY RECOMMENDED that he or she wear a mouth guard for all practices and games. FOR YOUR INFORMATION: Primary insurance covers the cost of the injury first. Secondary insurance (Holy Family s coverage) covers deductibles and the excess (remainder) of the costs. *Accidental dental insurance is different from dental insurance, which covers cleanings, cavities, and cosmetic work. Primary Medical Insurance and Accidental Dental Insurance Information Cardholder s Name: Relation: Cardholder s DOB: / /19 (mm/dd/year) SS#: - - Cardholder Employer: Insurance Co.: Type (please CIRCLE one) HMO POS PPO or Other: Policy #: Group #: Student Athlete s Policy # (If different): Insurance Co. Phone #: ( ) - Insurance Co. Address: City: State: Zip: SEE REVERSE

2 Secondary Insurance Information Cardholder s Name: Relation: Cardholder s DOB: / /19 (mm/dd/year) SS#: - - Cardholder Employer: Insurance Co.: Type (please CIRCLE one) HMO POS PPO or Other: Policy #: Group #: Student Athlete s Policy # (If different): Insurance Co. Phone #: ( ) - Insurance Co. Address: City: State: Zip: Dental Insurance Information Cardholder s Name: Relation: Cardholder s DOB: / /19 (mm/dd/year) SS#: - - Cardholder Employer: Insurance Co.: Type (please CIRCLE one) HMO POS PPO or Other: Policy #: Group #: Student Athlete s Policy # (If different): Insurance Co. Phone #: ( ) - Insurance Co. Address: City: State: Zip: I, have read and understood the Holy Family University Athletic Insurance Policy. I understand that should I not be covered by accidental dental insurance, it is mandatory that I wear a mouth guard for all practices and games. Failure to do so will place the responsibility of complete payment for resulting injuries on me and/or my parents. I hereby certify that the above information is complete and accurate to the best of my knowledge. I understand that there are legal penalties for filing a false claim or for failing to reveal material facts about a claim. Student-Athlete Signature: : Parent/Legal Guardian Signature: (even if over 18) :

3 Student Athlete Emergency Contact Information PLEASE PRINT ALL INFORMATION CLEARLY AND COMPLETELY! Student Athlete Contact Information Sport: Year of eligibility (Circle one): [ Freshman, Sophomore, Junior, Senior ] Name: DOB: (MM/DD/YEAR) Residence Hall/Duplex: Rm#: Local Address (if off campus): Cell Phone#: ( ) - Home Phone#: ( ) - Address: Primary Contact Information (in case of an emergency) Name: Relation: Address: City: State: Zip: Cell Phone#: ( ) - Home Phone#: ( ) - Work Phone#: ( ) - Extension: Secondary Contact Information (in case of an emergency) Name: Relation: Address: City: State: Zip: Cell Phone#: ( ) - Home Phone#: ( ) - Work Phone#: ( ) - Extension: Athlete s Primary Care Physician (REQUIRED) Physician s Name: Office Phone#: ( ) - Allergies (food or medicine): Please indicate None, if no known allergies. List any current Medications: Please indicate None, if no current medications.

4 CONCUSSION POLICY The Holy Family University Department of Athletics has recognized that concussions pose a significant health risk for those students participating in athletics. With this in mind, the Department of Athletics, through the Athletic Training staff, has implemented policies and procedures to assess and identify those studentathletes who have suffered a concussion. The Athletic Training staff also recognizes the importance of baseline neurocognitive testing on all student-athletes especially those with a history of concussions prior to entering Holy Family University. The baseline neurocognitive testing provides the athletic training staff with significant data as part of a return-to-play decision, if necessary. The baseline data, physical examination, and/or further diagnostic testing will be used in determining the student-athlete s status to return to play. In an effort to limit the risks of concussions associated with athletics, and the potential catastrophic and long-term complications from concussions, Holy Family University s Athletic Training staff will take a proactive philosophy in the assessment and management of concussions. To maximize the safety of the student-athlete and to obtain the most accurate interpretation of neurocognitive testing, it is the responsibility of the student-athlete to truthfully report any and all history of concussions to the Athletic Training staff. Failure to do so may influence the outcomes, recovery, and treatment, placing the student-athlete at risk of second impact syndrome. What is a concussion? It is the violent shaking or jarring action to the brain, usually as a result of impact with an object, the ground, or another person. This results in immediate partial or complete impairment of neurological function (disruption of the function of the brain). Significant head injury may not be readily observable for hours after initial trauma. Therefore, even seemingly insignificant head trauma should be reported immediately and thoroughly assessed. Even if symptoms do not immediately occur they must be reported. Neurocognitive testing All Holy Family University student-athletes will be ImPACT* tested prior to participating in any sports activity for the purpose of establishing a baseline using this software. Student-athletes baseline testing will be re-tested every other year that they remain eligible as a student-athlete at Holy Family University.

5 Signs and symptoms of a concussion (but are not limited to the following): Physical Symptoms Cognitive Symptoms Emotional Symptoms -Headache -Memory Loss -Irritability -Vision Difficulty -Attention Disorders -Sadness -Nausea -Reasoning Difficulty -Nervousness -Dizziness/balance issues -Slurred or incoherent speech -Sleep Disturbances -Balance Difficulties -Light and/or Noise Sensitivity -Fatigue Holy Family University Concussion Policy All Holy Family University student-athletes will be ImPACT* tested prior to participating in any sports activity for the purpose of establishing a baseline using this software. Student-athletes baseline testing will be re-tested every other year that they remain eligible as a student-athlete at Holy Family University. If a concussion is suspected or occurs, the following steps will be followed: 1. The student-athlete is immediately removed from practice or competition and is to be evaluated by Holy Family s Certified Athletic Training staff or Team Physician or the host team s Certified Athletic Trainer. 2. A student-athlete shall not return to any physical activity until medical clearance has been granted by Holy Family s Athletic Training staff or the Team Physician. 3. Student-athletes with a concussion will report to the ATC for continued monitoring as needed specified by the ATC. 4. Referral to a physician or emergency care will be determined on a case by case basis. If no immediate referral is necessary, the student-athlete will be sent to their on- campus residence with the Head Injury Warning Information sheet to be shared with the person responsible for monitoring the student-athlete. The Residence Advisor (RA) will also be contacted and informed of the situation. In addition, the Athletic Trainer will the Director of Residence Life detailing the incident and management of the condition. Arrangements will be made by the Athletic Trainer to transport the student-athlete to their on-campus residence. If the studentathlete commutes, the Athletic Trainer, with the permission of the student-athlete, will make every effort to contact the parent or guardians by phone to arrange transportation. However, the first means of transporting student-athletes off-campus residence will be the responsibility of the parent or guardian. If this is not possible, alternative means will be arranged by the Athletic Trainer. A Head Injury Warning Information sheet will also be sent home with the studentathlete.

6 5. A follow-up post-concussion ImPACT test will be administered within 24 hours of the incident. These scores will be compared to the student-athlete s baseline testing. Follow-up ImPACT testing will continue after the student-athlete reports that he/she is asymptomatic for 24 hours. 6. Following ImPACT post-concussion return-to-baseline clearance, the athlete will begin a returnto-activity progression. 7. Return-to-play will occur upon the completion of the return-to-activity progression without the reoccurrence of any symptoms. Final authority for return-to-play shall reside with the Team Physician or the Holy Family University Certified Athletic Trainer. I,, have read and understood the Holy Family University Concussion Policy. I understand that if I do not follow this policy, appropriate disciplinary measures will be taken by the Department of Athletics. Signature of Student-athlete Signature of Parent/Guardian (even if over 18)

7 SICKLE CELL POLICY About Sickle Cell Trait Sickle cell trait is an inherited blood disorder of the oxygen carrying protein, hemoglobin, in the red blood cells. Red blood cells are cells that carry oxygen through the human body. Sickle Cell Trait is usually benign, but during intense, sustained exercise, hypoxia (lack of oxygen) in the muscles may occur causing sickling of the red blood cells (red blood cells changing from a normal disc shape to a crescent or sickle shape), which can accumulate in the bloodstream and block normal blood flow to tissues and muscles, leading to collapse from the rapid breakdown of muscles starved of blood. Sickle Cell Trait means that a person carries enough genetic material to pass on the trait to his or her children. If a person receives a sickle cell gene from both parents, the person will inherit sickle cell disease. If he or she inherits only one sickle cell gene, then he or she is said to have sickle cell trait. Individuals with Sickle Cell Trait usually do not get sickle cell disease, but under certain extreme conditions (especially dehydration and high altitudes), some sickling may occur. Common signs and symptoms of a sickle cell emergency include, but are not limited to: Increased pain and weakness in the working muscles (especially the legs, buttocks, and/or lower back); Cramping of muscles; Soft, flaccid muscle tone; and/or Immediate symptoms with no early warning signs. Some conditions that can increase the likelihood of sickle cell emergency include, but are not limited to: infection, overexertion, dehydration, stress, heat, asthma, and high altitude. To find out more about Sickle Cell Trait, information may be found at the NCAA website located at (go to the Health and Safety tab, click on the section titled Sickle Cell Trait Materials and Resources ). You can also contact any member of the Holy Family University athletic training staff for any additional questions or concerns. Holy Family University Policy NCAA Division II, bylaw , legislation requires ALL institutions, as part of the required medical examination, to include: a. A sickle cell solubility test; b. Produce medical documented results of a prior test to the institution; or c. The student-athlete declines the sickle cell solubility test and signs a written release. In accordance with this legislation, Holy Family University has implemented the following policy, effective immediately, for all student-athletes: Prior to participation in any athletically-related activities, including but not limited to: practices, contests, conditioning, and tryouts, all student-athletes must sign Holy Family University s Sickle Cell Trait Testing/ Informed Consent Form, and decide on a course of action regarding sickle cell trait testing. The course of action options are: a. Obtain a sickle cell solubility test, and provide results;

8 b. Produce medical documentation of a prior sickle cell solubility test; or c. Decline the sickle cell solubility test and sign a written release. A Student-athlete, who chooses to be sickle cell trait tested, must provide medical documentation of the results. The results must be on file with the certified athletic training staff prior to beginning any athletics participation. Holy Family University is not responsible for any fees that may be incurred as a result of sickle cell trait testing and/or fees associated with obtaining a copy of prior sickle cell trait test results. To verify testing at birth, the student-athlete can contact his or her primary care physician or the hospital where he or she was born. If performed, a copy of the sickle cell solubility test results must be on file with the certified athletic training staff prior to beginning any athletics participation. Any student-athlete who choose not to acquire and submit medical documentation or does not wish to undergo testing to determine his or her sickle cell trait status must sign the Holy Family University Sickle Cell Testing/Informed Consent Form indicating the student-athlete has been educated and informed regarding sickle cell trait and its implications in athletics participation. Student-Athletes who test positive for Sickle Cell Trait: If a student-athlete has tested positive for sickle cell trait, the student-athlete can continue to participate in athletics without significant restrictions. An individualized protocol (see Protocol on page 3) will be developed and implemented under the direction of the team physician, Holy Family University s certified athletic training staff, and head coach to help reduce the risk of a sickle cell trait-induced health problem due to participation in training or competition. The student-athlete assumes all risks of having Sickle Cell Trait or Disease associated with athletics participation. The student-athlete also agrees to exonerate, safe harmless, and release Holy Family University, its agents, servants, and employees from any and all liability, including claims of negligence, on the part of Holy Family University, related to his or her participation in athletics. Additionally, it is important to note that the risk of complications due to sickle cell trait cannot be completely eliminated; therefore, each student-athlete remains responsible for the monitoring of his or her own health and takes precaution to reduce risks associated with sickle cell trait or any other health condition. Holy Family University Sickle Cell Trait Protocol: Student-Athletes identified with Sickle Trait: a. The student-athlete will watch the NCAA education video about sickle cell trait and athletic participation; b. The student-athlete will meet with the certified athletic training staff and/or the team physician to answer any questions he or she may have and make sure the student-athlete understands what it means to carry the sickle cell trait. The student-athlete will be provided the necessary steps he or she must take to remain safe while participating (staying hydrated, recognizing early symptoms of heat illness/sickle cell crisis, and report any illness to certified athletic training

9 staff and coaches immediately). In addition, a sickle cell fact sheet will be provided and reviewed with each student-athlete; c. The student-athlete, certified athletic training staff member, team physician, and parent or legal guardian will sign the Sickle Cell Positive Notification Form confirming review of sickle cell trait and recommendations regarding his or her course of treatment and care; d. Holy Family University s sport coaches and strength and conditioning personnel will be notified of the student-athlete s trait status to ensure that the student-athlete is permitted access to fluids as needed, is not forced to participate in timed physical tests before becoming acclimated to heat and exertion at the beginning of a sports season, and any student-athlete complaints of exhaustion are taken seriously and activity stopped immediately until evaluated by an certified athletic training staff member; and e. It is general practice that Holy Family University s sport coaches monitor all student-athletes closely during official practices and workouts and encourage adequate hydration. Coaches will additionally be educated and informed of those with sickle cell trait, and pay added attention to these individuals. The certified athletic training staff will monitor environmental conditions and possibly limit or halt exercise if risk is determined to be high. I,, have read and understood the Holy Family University Sickle Cell Policy. I understand that if I do not follow this policy, it will delay my participation in Holy Family University s Department of Athletics. Signature of Student-athlete Signature of Parent/Guardian (even if over 18) Holy Family University

10 Sickle Cell Testing Informed Consent Form Student-Athlete Name: : of Birth: Sport: In NCAA Division II, bylaw has been adopted that requires institutions, as part of the medical examination required before participation in any athletically-related activities, to include: 1. A sickle cell solubility test; 2. Documented medical results of a prior test are provided to the institution; or 3. The student-athlete declines the test and signs a written release. This legislation is applicable to student-athletes who are beginning his or her initial year of eligibility, transfer studentathletes, and all returning student-athletes. Under NCAA guidelines, student-athletes who choose to have the test performed will not be permitted to participate in athletically-related activities until a copy of the test results are on file with the Certified Athletic Training Staff. jkljkljkljklj Authorization for Sickle Cell Testing Please initial next to ONE option that you are choosing and sign and date at the bottom Student-Athlete Initials I agree to submit to a Sickle Cell Solubility Test prior to my participation in intercollegiate athletics at Holy Family University. I understand that I will not be permitted to begin any athletics participation until a copy of the test results are on file with the Certified Athletic Training Staff. I understand that Holy Family University is not responsible for any fees associated with testing. OR Student-Athlete Initials I certify that I have already been tested for Sickle Cell Trait and will provide documentation to Holy Family University of results of this test for my medical file. I understand that I will not be permitted to begin athletics participation until a copy of the test results are on file with the Certified Athletic Training Staff. I understand that Holy Family University is not responsible for any fees associated with obtaining a copy of my prior sickle cell trait medical test results. OR Student-Athlete Initials I do not wish to be tested for Sickle Cell Trait. By refusing this test, I certify that I have read and understand the Holy Family University Sickle Cell Policy, and understand the risks involved with refusing this test. I voluntarily assume all risks of having Sickle Cell Trait or Disease associated with athletics participation and agree to exonerate, safe harmless, and release Holy Family University, its agents, servants, and employees from any and all liability, including claims of negligence, on the part of Holy Family University, related to my participation in athletics. Student-Athlete Signature Parent/Legal Guardian Signature (even if over 18)