Dear Concordia University Athletes and Parents, It is with great anticipation that we look forward to the coming athletic year where each athlete will be involved in competition as a representative of our University in what we hope will be a great year for Eagle Athletics. This letter is to bring you up to date with the medical clearance requirements and potential injury insurance information for the Athletic Training department. The attached medical packet (also located at www.cuieagles.com under Athletics, Athletic Training, and Athletic pre-participation forms) must be completed prior to the first day of practice. One major area the athletic department must cover with parents is the area of potential injury. Each athlete must be covered under their own (or parent s) primary insurance plan (plan must be approved at www.cui.edu/insurance). The athlete must waive the Concordia Insurance Primary Plan if their personal coverage is accepted (www.cui.edu/insurance). The athlete may also choose to purchase the Concordia Plan for primary coverage, which will be billed to their account. To be covered under Concordia s secondary athletic insurance (after primary has been billed) the injury must be sustained as a part of a team practice, game, scrimmage, work out, or transportation to/from an intercollegiate athletic event. A report must be immediately filed with one of the Certified Athletic Trainers. All Athletes Athletic Training Requirements: On campus physical during move in weekend (no outside physicals accepted) Insurance/Emergency Form (parent signature if under 25) Waive or purchase insurance and follow directions from Jully 7th- Aug. 31st at: www.cui.edu/insurance Copy of Insurance Card front and back Health History Form and Immunizations should be forwarded to wellness center online via cui.medicatconnect.com Note: *International Students MUST purchase Concordia Student Health Insurance Plan (it cannot be waived) *Mandatory Athletic Physicals will be administered on campus free of charge during move in weekend or specified time for each team. There will be no co-pay but will be routed to primary insurance for reimbursement. * Please send explanation of benefits page or insurance statements to Glory Fung (Fax: 949-214-3245 or glory.fung@cui.edu) Please email (jessina.manio@cui.edu), mail (Concordia University Athletic Training Attn: Jessina Manio, 1530 Concordia West, Irvine, CA, 92612), or fax (949-214-3246) the materials to Jessina Manio by July 25 th. Sincerely, Jessina Manio, MA, ATC Assistant Athletic Trainer 949-214-3246
HEALTH RECORD AND EXAMINATION To be completed by M.D./N.P./P.A. Last Name First Name Middle Name Date of Birth Age Sex Student ID#: E Blood pressure Pulse rate Height Weight Vision: R20/ L20/ Corrected: Y / N Pupils Equal: Y / N Allergies: Drugs Food Bee/Other MEDICAL NORMAL ABNORMAL FINDINGS INITIALS Appearance Eyes/Ears/Nose/Throat Lymph Nodes Heart Pulses Lungs Abdomen Genitals (males only) Skin MUSCULOSKELETAL Neck Back Shoulder/Arm Elbow/Forearm Wrist/Hand Hip/Thigh Knee Leg/Ankle Foot CLEARANCE Cleared Cleared after completing evaluation/rehabilitation for: Not cleared for: Reason: Recommendations: Healthcare Provider s Signature: (not valid without office stamp) Date: Required Immunizations and Tuberculin Test MMR (Measles, Mumps, Rubella) 2 doses required given on or after first birthday Dose #1 / / given at least 28 days after the first dose Dose #2 / / Tdap (Tetanus, diphtheria, pertussis) given within the last 5 years / / MENINGITIS (Groups A/C/Y/W 135) given within the last 5 years / / TUBERCULIN TEST (PPD-Mantoux) completed within the last 12 months Date given: / / Date Read: / / Result: mm induration Negative / Positive If positive, please obtain chest x-ray and send copy of report. Recommended Immunizations Hepatitis A Dose #1 / / Dose #2 / / Hepatitis B Dose #1 / / Dose #2 / / Dose #3 / / Varicella (chicken pox): Dose #1 / / Dose #2 / / Disease date / / *** If student is unimmunized due to religious, personal, or medical reasons, please notify us. Healthcare Provider s Signature: (not valid without office stamp) Date:
CONCORDIA UNIVERSITY ATHLETICS INSURANCE FORM YEARLY UPDATE PLEASE COMPLETE FULLY. DO NOT LEAVE ANY BLANK SPACES. NOTIFY US IMMEDIATLEY IF ANY INFORMATION CHANGES. ***STUDENT INFORMATION*** Name (Last, First) Sport(s) Home Address City State Zip Cell Phone Number SS# Date of Birth In case of emergency, please notify: Name Relationship: Address City State Zip Home phone: Cell phone Work phone Allergic reaction to: Medications currently taken: Pre-existing Medical Conditions (include surgeries, injury, or illness within past year). ***INSURANCE COMPANY INFORMATION*** Insurance Company Policy Number Insurance Phone# : Concordia Insurance ***If it is an HMO, it is strongly suggested that you switch the Primary Care Physician to one located near the Irvine area while your son/daughter is enrolled at Concordia. The HMO requires Concordia to use the Primary Care doctor listed on your insurance card. This means that if that doctor is not located nearby then the only other option is the emergency room, which results in a wait of several hours for simple maladies such as a sore throat, x-rays, etc.*** ***It is very important that you notify the athletic trainer of any changes in your medical insurance status. Falsifying information or terminating your insurance coverage may result in player ineligibility. If you do not have insurance and a claim is submitted, you and/or your parents or guardian will be responsible for any fees incurred. All unpaid claims will be sent to a collection agency.*** ***POLICY HOLDER INFORMATION*** Name of Policyholder (Last, First) Address City State Zip Date of Birth SS# Please return this form with a copy of the student s insurance card (continued on reverse side)
ASSUMPTION OF RISK/VERIFICATION OF INSURANCE This is to verify that the above named insurance policy will apply to injuries and follow up care incurred as a result of athletic participation for Concordia University and that it will pay for medical charges incurred at any location where illness, injury or follow up treatment should occur. Concordia University athletic insurance covers only accidental bodily injuries occurring as a direct result of athletic participation. Concordia University s insurance will not cover any charges due to re-injury of a previous medical condition. In consideration of Concordia University permitting my son/daughter to try out for Concordia Athletics and to engage in all activities related to the team, including, but not limited to trying out, practicing or playing in that sport, I hereby assume all the risks of my son/daughter associated with participation and agree to hold Concordia University, its employees, agents, representatives, coaches, and volunteers harmless from any and all liability, actions, causes of action, debts, claims, or demands of any kind and nature whatsoever which may arise by or in connection with his/her participation in any activities related to Concordia University athletics. The terms hereof shall serve as a release and assumption of risk for my son s/daughter s heirs, estate, executor, administrator, assignees, and for all members of his/her family. I have read and understand the risks as detailed in this agreement. Parent/Guardian signature is required for single students under the age of 25. SIGNATURE OF PARENT/GUARDIAN: DATE: PRINT NAME OF PARENT/GUARDIAN: Include a photocopy of your health insurance card, front and back. I am aware that playing/participating in any sport can be dangerous in nature involving MANY RISKS OF INJURY. I understand that the dangers and risks of playing include, but are not limited to, death, serious neck and spinal injury, injury to all parts of my body, and other aspects of the systems of the body. I understand that the dangers and risks of playing may result not only in serious injury, but in a serious impairment of my future abilities to earn a living, to engage in other business, social and recreational activities, and generally to enjoy life. Because of the dangers of participation, I recognize the importance of following coaches and medical staff instructions regarding playing techniques, training and other team rules, etc., and agree to obey such instructions. In consideration of Concordia University permitting me to try out for the Concordia University athletic teams and to engage in all activities related to the team, including, but not limited to, trying out, practicing or playing in that sport, I hereby assume all the risks associated with participation and agree to hold Concordia University, its employees, agents, representatives, coaches, and volunteers harmless from any and all liability, actions, causes of actions, debts, claims or demands of any kind and nature whatsoever which may arise by or in connection with my participation in any activities related to Concordia University athletic teams. The terms hereof shall serve as a release and assumption of risk for my heirs, estate, executor, administrator, assignees, and for all members of my family. I have read and understand the risks as detailed above for my participation in Concordia Athletics. I understand that it is my responsibility to fill out the online waiver at www.cui.edu/insurance, by the deadline, to prevent charge to be posted on my student account. SIGNATURE OF STUDENT: DATE: PRINT NAME OF STUDENT:
H I S T O R Y CONCORDIA UNIVERSITY IRVINE Athletics Pre-Participation Physical Questionnaire Date of Exam Name Sex Age Date of Birth Sport Address Phone Personal Physician E#: In case of emergency: Name Relationship Phone (H) (C) Explain Yes answers below. Circle questions you don t know the answers to. 1. Have you had a medical illness or injury since your last check up or sports physical? Do you have an ongoing or chronic illness? YES NO YES NO 10. Do you use any special protective or corrective equipment or devices that aren t usually used for your sport or position (knee brace, special neck roll, foot orthotics, retainer on your teeth, hearing aid)? 2. Have you ever been hospitalized overnight? Have you ever had surgery? 11. Have you had any problems with your eyes or vision? Do you wear glasses, contacts or protective eyewear? 3. Are you currently taking any prescription or 12. Have you ever had a sprain, strain or swelling after nonprescription (over-the-counter) medications or injury? pills or using an inhaler? Have you broken or fractured any bones or dislocated Have you ever taken any supplements or vitamins any joints? to help you gain or lose weight or improve your Have you had any other problems with pain or performance? swelling in muscles, tendons, bones or joints? 4. Do you have any allergies (pollen, medicine, food If YES, check appropriate box and explain below. or stinging insects)? Head Elbow Hip Have you ever had a rash or hives develop during or Neck Forearm Thigh after exercise? Back Wrist Knee 5. Have you ever passed out during or after exercise? Chest Hand Shin/calf Have you ever been dizzy during or after exercise? Shoulder Finger Ankle Have you ever had chest pain during or after exercise? Upper arm Foot Do you get tired more quickly than your friends do 13. Do you want to weigh more or less than you do now? during exercise? Do you lose weight regularly to meet weight Have you ever had racing of your heart or skipped requirements for your sport? heartbeats? 14. Do you feel stressed out? Have you had high blood pressure or high cholesterol? 15. FEMALES ONLY Have you ever had a heart murmur? When was your first menstrual period? Has any family member or relative died of heart Most recent menstrual period? problems or of sudden death before age 50? How much time usually passes from the start of one Have you had a severe viral infection (myocarditis or period to the start of another? mononucleosis) within the last month? 16. How many periods have you had in the last year? Has a physician ever denied or restricted your What was the longest time between periods in participation in sports for any heart problems? the last year? 6. Do you have any current skin problems (itching, rashes, acne, warts, fungus or blisters)? EXPLAIN ALL YES ANSWERS HERE: 7. Have you ever had a head injury or concussion? Have you ever been knocked out, become unconscious or lost your memory? Have you ever had a seizure? Do you have frequent or severe headaches? Have you ever had numbness or tingling in your arms, hands, legs or feet? Have you ever had a stinger, burner or pinched nerve? 8. Have you ever become ill from exercising in the heat? 9. Do you cough, wheeze or have trouble breathing during or after activity? Do you have asthma? Do you have seasonal allergies that require medical treatment? I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. I understand that inaccurate, false or missing information may invalidate the examination. Signature of Student Athlete: Date: Signature of Parent (if student-athlete is under 18)