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Dear Student-Athlete, Welcome back to Western Illinois University! The Sports Medicine Department provides comprehensive medical care for injuries and illnesses suffered while competing as a WIU student-athlete. This letter provides information regarding medical and insurance paperwork that needs to be completed and on file before you are able to practice with your team. You are responsible for filling out all of the information asked for on the medical/insurance forms. Obtaining all of this information is vital to our department in allowing us to guarantee a smooth transition for the injured student-athlete through our referral process. All student-athlete medical/insurance forms can be found online at www.goleathernecks.com under the Student- Athletes tab on the website. When you arrive on campus, it is very important that you bring each of your insurance cards (medical, prescription, dental and/or vision) to carry with you at all times to present to Athletic Training Services, the Western Illinois Sports Medicine and Orthopedic Center, McDonough District Hospital, and Beu Student Health Clinic, for medical appointments, treatments, and when picking up prescriptions at the pharmacy. You can be helped much faster if you can present your current & active insurance card. In addition, please send along quality front/back copies of those cards with the Parent Primary Insurance Questionnaire Form. The University provides secondary insurance coverage in the event the student-athlete sustains an injury/illness while participating in WIU Intercollegiate Athletics. This will cover excess medical bills after the primary insurance has paid the claim. If you do not have primary health insurance, you will be required to have the general student health insurance through Beu Health Center s Blue Cross Blue Shield policy for students. All WIU students are required to have some type of primary health insurance coverage. Those with primary coverage comparable to WIU s general student health insurance may elect to waive their mandatory insurance fee through Beu Health Center s website. Please check in with your teams Certified Athletic Trainer when you report to campus to make sure all documentation is up to date and complete. Also, update your Athletic Trainer on any new health issue or concern that developed over the summer. Continue to be aware the NCAA has banned commonly prescribed medications for ADD/ADHD because they are performance enhancing stimulant drugs, and are being abused in the college environment. The NCAA has set up a medical exemption policy for students who have a legitimate medical need for these medications. The documentation needed to obtain a waiver is lengthy. Information regarding a waiver can be found with the rest of the medical forms on the website. Please print legibly, fill out completely, and sign on all forms. Make sure a parent/guardian signs if you are less than 18 years old. The next page has a checklist of the forms needed on file before you participate with your team, and instructions on how to return them. If you have any questions or concerns, please do not hesitate to contact one of the sports medicine staff members below. We appreciate your cooperation, and look forward to your career as a Leatherneck student-athlete. Sincerely, Chad Cerullo MS, ATC, LAT, CES Head Athletic Trainer Western Illinois University 1 University Cr 1 University Cr Macomb, IL 61455 Macomb, IL 61455 Molly Reis MA, ATC, LAT Director of Sports Medicine Western Illinois University 309-298-2340 309-298-1253 c-cerullo@wiu.edu ml-reis@wiu.edu

Checklist: Parent Primary Insurance Questionnaire Copy of Insurance Cards Front/Back (Health, Prescription, Dental, Vision) Returning Student-Athlete Medical History Form HIPPA-Authorization to Disclose Protected Health Information Student-Athlete Concussion Statement www.goleathernecks.com http://www.wiu.edu/student_services/beu_health_center/ Return forms by bringing them to campus during your reporting date and/or mailing them to: Western Illinois University Intercollegiate Athletics-Western Hall attn: Athletic Training Dept 1 University Cr Macomb, IL 61455

WIU STUDENT-ATHLETE INSURANCE INFORMATION (as of4/11/14) PLEASE KEEP THIS FACT SHEET FOR YOUR RECORDS!!! We are extremely pleased to have your son/daughter as a student-athlete at Western Illinois University and hope he/she will achieve academic and athletic success at Western. Injuries do occur, and we attempt to provide our athletes with the very best possible care. Athletic Accident Insurance is provided by our institution for the benefit of our student-athletes. This coverage is offered on an excess basis only. Under the terms of the policy, this coverage is considered to be excess to all other valid and collectible medical insurance policies. Most notable would be the parental insurance coverage through your place of employment under which the student-athlete is covered as an eligible dependent. ATHLETIC ACCIDENT INSURANCE A. The NCAA does not permit Western Illinois University or any college/university to provide coverage or pay bills incurred for expenses which are not sustained as the direct result of an accident in our intercollegiate sports program. B. Athletes listed on team rosters are automatically covered by this program at no cost to the student. All accidents must occur during NCAA regulated practice/season. Athletes must be referred by a certified athletic trainer to be eligible for coverage. This does not necessarily mean that the athletic department will pay for the medical service. C. Coverage extends for a 104-week period from the date of the original injury. D. Athletic insurance is SECONDARY/EXCESS COVERAGE ONLY, payable only after claims have been submitted to parents primary carrier and a copy of the Explanation of Benefits (indicating partial payments, applied to deductible, etc.) and a copy of the original bill have been received in the insurance office. E. We must know the medical coverage you have to avoid delays in the processing of a claim. The Insurance Questionnaire form must be completed and all requested information be included in its entirety. Parents/Guardians should sign and date the form at the bottom and return it to WIU Athletics Dept. STUDENT HEALTH INSURANCE A. Mandatory for all WIU students to have some type of primary insurance coverage B. Claims filed through Student Health Benefits (phone 309/298-1882) if the claim was NOT a result of an athletic injury, and student is covered under the insurance plan offered by the University. C. Western Illinois University students who participate in Intercollegiate Athletics will be mandated to participate in the University s Student Insurance Program if they do not have applicable primary insurance of their own. This policy will remain in effect each semester a student participates in Intercollegiate Athletics. D. All WIU full-time students will have a fee for this coverage. This applies to student-athletes. A waiver will be available to current student-athletes who have primary insurance coverage that is comparable or better than what WIU requires of general student health insurance. Waiver information may be obtained online at http://www.wiu.edu/student_services/beu_health_center/ Please remember that athletic accident insurance coverage for your son/daughter is SECONDARY/EXCESS COVERAGE ONLY. All claims must first be submitted to your own primary insurance plan. The information that is requested on the Insurance Questionnaire is extremely crucial to the success of processing insurance claims. Your failure to fill this out correctly will result in delays in processing claims. This delay may have possible credit issues for the student-athletes with medical providers. If you have any questions at this time or during the school term, please feel free to contact the Insurance Office at 309/298-1882.

2015-2016 PARENT PRIMARY INSURANCE QUESTIONAIRE *PLEASE INCLUDE A COPY OF YOUR MEDICAL INSURANCE CARDS (FRONT AND BACK SIDES)* PLEASE PRINT ALL INFORMATION! FAILURE TO COMPLETE ALL BLANKS WILL RESULT IN CLAIMS PROCESSING DELAYS. NOTE: Complete all banks with information or n/a if not applicable. Name: WIU ID #: School address: Cell Phone: Home address: Sport: Birth date: E-mail address: Father/Guardian: Phone: E-mail address: Mother/Guardian: Phone: E-mail address: Father s Employer: Phone: Mother s Employer: City/St/Sip: Phone: DOES THE WIU ATHLETE HAVE MEDICAL COVERAGE THROUGH THEIR PARENT/GUARDIAN? Father? Yes No Mother? Yes No Father s Medical Insurance Company/Plan: Mother s Medical Insurance Company/Plan: Policy # Policy # Phone #: Phone #: Father s Date of Birth: Mother s Date of Birth: PLEASE INCLUDE A COPY OF YOUR MEDICAL INSURANCE CARD! PLEASE INCLUDE A COPY OF YOUR MEDICAL INSURANCE CARD! ***MUST***PRE-PHYSICAL/All prospective athletes should bring any medical records that they have regarding pre-existing conditions (i.e., past injury, sickness, special medical condition, x-rays, shot records) ; any absence of this material might delay approval of their university physical. ATHLETES WHO HAVE HAD RECENT MEDICAL TREATMENT (SURGERY, FRACTURES, REHAB, ETC.) OR ARE STILL UNDER A PHYSICIAN S CARE NEED TO PROVIDE A SIGNED PHYSICIAN RELEASE IN ORDER TO BE CLEARED FOR PRACTICE OR PLAY. I/We agree that all information provided in this document is accurate and complete to the best of my/our knowledge. I/We understand that any incorrect or undisclosed information can result in duplicate payments, creating a substantial overpayment. The responsibility of such overpayment will be the obligation of the undersigned to reimburse in full, upon request, all amounts deemed refundable. I hereby give my consent to the Physician Representative of Western Illinois University s Athletic Department and the Athletic Training personnel in that department to perform emergency and first aid treatment to my relative to injuries sustained during practices for and participation in various athletic contests and events as well as injuries sustained during transportation to or from such practice or contest sessions. I hereby agree to have any insurance provider information released to medical vendors. Student-Athlete Signature Date Parents/Guardian Signature Date (only required If under 18 years old) Return to: Athletic Training Department, Western Illinois University, 1 University Circle, Macomb IL 61455-1390

AUTHORIZATION TO RELEASE MEDICAL INFORMATION PATIENT NAME (Please print): Last Name First Name MI Date of Birth Beu Health Center 1 University Circle, WIU Macomb, IL 61455 Phone (309) 298-1888 FAX (309) 298-2188 Address 9-digit WIU Student ID # Local Phone RELEASE FROM: RELEASE TO: Beu Health Center Name: Beu Health Center Name: Address City Address City State Zip FAX State Zip FAX PURPOSE: Patient s Request Continuing Treatment Legal Insurance Other : DATES OF RECORDS TO BE RELEASED: From: / / To: / / SPECIFY RECORDS TO BE RELEASED: Allergy Records X-ray report X-ray CD Physical Exam Laboratory Results Immunization records TB tests Clinic Notes Other (Specify): Entire Health Record ($20.00 Charge applies). There is no charge to mail health record to another healthcare professional (e.g. physician). Entire health record will not be faxed. By initialing the boxes below, I am authorizing the release of the following information: Alcohol and/or drug abuse treatment information (as protected under 42 CFR) HIV/AIDS Information (as defined by Illinois Statute) Mental Health Records (as defined by the Illinois Mental Health and Developmental Disabilities Confidentiality Act) This consent will terminate upon (specific date, event or condition):. I understand that I may revoke this consent at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it. Acting in reliance includes the provision of treatment services in reliance on a valid consent to disclose information to a third party payer. If no calendar date is specified above, Mental Health Records may only be released on the date this release is received by our office. NOTICE TO PATIENT: I fully understand that my medical record and health information for the above date(s) may contain alcohol/drug abuse, and/or HIV/AIDS test results, mental health information and/or other information.* I understand that any of the above selected records may contain medical information from outside sources and authorize Beu Health Center to release these records and health information if necessary for the continuity of care or if I have requested my complete record. I understand that I have the right to inspect and/or obtain a copy (for the appropriate fee) of my medical record prior to disclosure. I understand that this consent applies both to written and verbal release of information. I absolve, discharge, release, & hold harmless the Board of Trustees for Western Illinois University together with its agents and employee for any legal liability, claims, or damages which may arise from the disclosure of this information. * To receiving agency: these records may not be re-disclosed without the patient s consent. Signature of patient or authorized legal guardian Relationship to patient, if signed by authorized representative Witness signature (required for mental health/hiv/substance abuse) Date Date Date FOR OFFICE USE ONLY: Date prepared: Date Mailed/Faxed: Date given to student: Fee: Initials: Initials: Initials: Green Task Completed? Rev.09.10

WESTERN ILLINOIS UNIVERSITY AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION (HIPPA) I hereby authorize the Western Illinois University Athletics and its members and staff (including but not limited to, team physicians, certified athletic trainers, team chiropractor, team dentists, team physical therapists) (Collectively identified as WIU/ST ) to use or disclose my injuries and my status ( protected health information ) as it effects my participation in sports to: 1. News media, including but not limited to, newspaper reporters (daily and fan), electronic media (radio and television), recognized Internet website reporters; and 2. WIU sport coaching staff, WIU athletic director, WIU President, and other WIU officials with a need to know in order to perform official WIU business, and my parent/guardians unless otherwise told not to do so 3. Members of scouting, coaching and athletic training staffs of professional athletic teams. WIU seeks to use or disclose the protected health information for the following purposes: 1. To provide information about the condition of WIU athletes to the public through the various news media, whether such disclosure is either initiated by WIU officials or staff members or whether such disclosure is in response to inquiries made by the various news media. 2. To provide information about the condition of WIU athletes to WIU officials and staff who have a need to know each athlete s condition for purposes of the official or staff member performing duties assigned to that official or staff member as part of that official or staff member s WIU duties. 3. To provide information about the condition of WIU athletes to members of scouting, coaching and athletic training staffs of professional athletic teams whether such disclosure is either initiated by WIU officials or staff members or whether such disclosure is in response to inquiries made by officials and staff members of professional athletic teams. I acknowledge, understand and authorize the use and disclosure of the protected health information and understand that it includes, but is not limited to, all protected health information such as protected health information related to injuries on the following list: joint sprains, bone fractures, muscle strains, joint cartilage injuries, contusions, lacerations, tendonitis, bursitis, disc disease, concussions, allergies, respiratory infections, asthma, G.I. distress (nausea, etc.). I acknowledge and understand that treatment, payment, and enrollment in any health plan, or eligibility for medical benefits is not conditioned on me signing this Authorization. However, I understand that Western Illinois University may condition their decision to permit me to participate in sports activities and events as part of a WIU sports team on whether I do or do not grant this authorization. I understand that upon request I may inspect or copy the protected health information to be used or disclosed. I understand that I may refuse to sign this Authorization if I so choose. The WIU/ST may use or disclose such protected health information until 545 days from the date of signature at which time this authorization shall expire. I understand that I retain the right to revoke this Authorization and that such revocation must be submitted to the WIU/ST in writing. The revocation shall be effective except to the extent that the WIU/ST has already used or disclosed information in reliance on the Authorization. I understand that I may revoke this Authorization by submitting my written revocation to: Molly Reis Associate Athletic Trainer/Director Sports Medicine Western Illinois University One University Circle Macomb, IL 61455 I have been informed and I understand that information used or disclosed pursuant to this Authorization may be subject to redisclosure by the recipient of such information, and, at that point, the information may no longer be protected under the terms of this agreement. I HAVE READ AND UNDERSTAND THIS INFORMATION. I HAVE RECEIVED A COPY OF THIS FORM. Signature of Athlete Please Print Name Signature of Parent/Guardian (if athlete under age 18) Date: Time: Sport Date: Time:

WESTERN ILLINOIS UNIVERSITY SPORTS MEDICINE MEDICAL HISTORY QUESTIONNAIRE (RETURNING STUDENT ATHLETE) NAME: SPORT: WIU ID # HEIGHT: WEIGHT: CELL PHONE #: BIRTH DATE: AGE: E-MAIL: QUESTIONS YES NO 1. Are you allergic to any medication, food, etc.? If yes, please indicate: 2. Are you currently taking prescribed medication on a permanent or semi-permanent basis (birth control pills, tetracycline, ADD, ADHD meds etc.)? If yes, please indicate drug and reason it was prescribed: 3. Have you ever been told you have Sickle Cell Trait? 4. Has anyone in your family been told they have Sickle Cell Trait? 5. Did you obtain glasses or contacts over the summer? 6. Did you obtain any type of dental appliance over the summer? 7. Have you ever experienced a sudden or temporary loss of consciousness (syncope) following exercise, postural change, hyperventilation, or extreme heat exposure? If yes, explain circumstances: 8. Were you ever knocked out during the summer vacation? For how long were you knocked out? 9. Did you suffer a concussion without being knocked out over the summer? Were you put in the hospital because of it? 10. Did you suffer any broken bones/sprains/muscle strains or other serious injury during the summer? If yes, please describe: 11. Were you hospitalized this summer? What was the reason? 12. Any other illness/injuries we should know about, please indicate: ALL OF THE PRECEDING INFORMATION IS COMPLETE AND HONEST TO THE BEST OF MY KNOWLEDGE. SIGNED DATE Updated 3/30/2014

CONCUSSION A fact sheet for student-athletes What is a concussion? A concussion is a brain injury that: Is caused by a blow to the head or body. From contact with another player, hitting a hard surface such as the ground, ice or floor, or being hit by a piece of equipment such as a bat, lacrosse stick or field hockey ball. Can change the way your brain normally works. Can range from mild to severe. Presents itself differently for each athlete. Can occur during practice or competition in ANY sport. Can happen even if you do not lose consciousness. How can I prevent a concussion? Basic steps you can take to protect yourself from concussion: Do not initiate contact with your head or helmet. You can still get a concussion if you are wearing a helmet. Avoid striking an opponent in the head. Undercutting, flying elbows, stepping on a head, checking an unprotected opponent, and sticks to the head all cause concussions. Follow your athletics department s rules for safety and the rules of the sport. Practice good sportsmanship at all times. Practice and perfect the skills of the sport. What are the symptoms of a concussion? You can t see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. Concussion symptoms include: Amnesia. Confusion. Headache. Loss of consciousness. Balance problems or dizziness. Double or fuzzy vision. Sensitivity to light or noise. Nausea (feeling that you might vomit). Feeling sluggish, foggy or groggy. Feeling unusually irritable. Concentration or memory problems (forgetting game plays, facts, meeting times). Slowed reaction time. Exercise or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games may cause concussion symptoms (such as headache or tiredness) to reappear or get worse. What should I do if I think I have a concussion? Don t hide it. Tell your athletic trainer and coach. Never ignore a blow to the head. Also, tell your athletic trainer and coach if one of your teammates might have a concussion. Sports have injury timeouts and player substitutions so that you can get checked out. Report it. Do not return to participation in a game, practice or other activity with symptoms. The sooner you get checked out, the sooner you may be able to return to play. Get checked out. Your team physician, athletic trainer, or health care professional can tell you if you have had a concussion and when you are cleared to return to play. A concussion can affect your ability to perform everyday activities, your reaction time, balance, sleep and classroom performance. 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, and even death. Severe brain injury can change your whole life. It s better to miss one game than the whole season. When in doubt, get checked out. For more information and resources, visit www.ncaa.org/health-safety and www.cdc.gov/concussion. Reference to any commercial entity or product or service on this page should not be construed as an endorsement by the Government of the company or its products or services.

Student-Athlete Concussion Statement Check Box I understand that it is my responsibility to report all injuries and illnesses to a Certified Athletic Trainer and/or a University 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: (Please initial each line after you have read the statement) A concussion is a brain injury, which I am responsible for reporting to my Certified Athletic Trainer and/or University physician. A concussion can affect my ability to perform everyday activities, and affect reaction time, balance, sleep, and classroom performance. You cannot see a concussion, but you might notice symptoms right away. 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 my Certified Athletic Trainer. I will not return to play in a game or practice if I have received a blow to the head or body that results in concussion related symptoms. Following a concussion the brain needs time to heal. You are much more likely to have a repeat concussion if you return to play before your symptoms resolve. In rare cases, repeat concussions can cause permanent brain damage, and even death. Student-Athlete Signature Date Printed Name of Student Sport This form must be on file before any WIU athletic participation occurs. Please return this form along with the other documents to your teams Certified Athletic Trainer.