Saint Augustine s University New Student Athlete Information

Transcription

1 Saint Augustine s University New Student Athlete Information Name: Student ID #: Social Security #: DOB: Year: FR SO JR SR 5 th Sports: Cell: Permanent Mailing Address: City/St/Zip: Mother s Information Name: Father s Information Name: Address: Address: City/St/Zip: City/St/Zip: Home Phone: ( ) - Cell Phone: ( ) - Work Phone: ( ) - Home Phone: ( ) - Cell Phone: ( ) - Work Phone: ( ) - Primary Insurance Holder: Yes No Primary Insurance Holder: Yes No Emergency Contact #1 Emergency Contact #2 Name: Name: Relation: Relation: Home Phone:( ) - Home Phone:( ) - Emergency Medical Information Allergies (food, medications, insect bites etc.): Current Medications: Pre-existing Conditions:

2 Class: FR SO JR SR 5 th Sports: Please answer Yes or No to the following questions: YES NO GENERAL MEDICAL Have you ever had surgery or been hospitalized for ANY reason? Are you currently under a doctor s care for ANY reason? Have you ever experiences chest pain, fainting or light headedness during or after exercise? Have you ever been diagnosed with a heart condition? If Yes, are you under the care of a cardiologist? Have you ever been diagnosed with high blood pressure, high cholesterol or diabetes? Have you ever been diagnosed with exercise induced asthma? Do you currently use an inhaler to control exercise induced asthma? Do you have any allergies? (food, bug bites/stings etc.) Do you require an Epi Pen for any allergies? Have you ever been diagnosed with Anemia? Have you ever been tested for Sickle Cell Trait? If Yes, PLEASE PROVIDE WRITTEN DOCUMENTATION OF THE RESULTS Do you wear contacts or glasses? Do you have only 1 of a paired organ? If Yes, Please list. Do you require any special equipment to play sports? If Yes, Please list. Have you ever been diagnosed with a seizure disorder? If Yes, PLEASE PROVIDE WRITTEN DOCUMENTATION TO PARTICIPATE IN ATHLETICS FROM THE TREATING PHYSICIAN Have you ever tested positive for HIV/AIDS? Do you currently take any medication for ADD/ADHD? If Yes, THE NCAA REQUIRES YOUR PRESCRIBING PHYSICIAN TO COMPLETE THE ADD/ADHD MEDICAL REPORTING FORM FOUND ON OUR WEBSITE BEFORE PARTICIPATION Do you have any other medical condition we should be aware of? If Yes, Please List. Have you had regular menstrual cycles for at least 1 year? In the last year, have you missed any periods for any length of time? Are you or do you think you could be pregnant? Have you ever been treated for any menstrual disorders, ovarian cysts, etc.? If Yes, Please describe. Are you currently taking birth control? YES NO ORTHOPEDIC Have you ever had an injury, (ligament sprain, muscle/tendon strain etc.) that has caused you to miss more than 1 practice/game? If Yes, Please describe.

3 Do you have recurring back pain? If Yes, how long has it been a problem? Have you fractured a bone? If Yes, Which bone(s) and when? Have you ever dislocated or subluxed a joint? If Yes, which joint and when? Have you ever had a stress fracture? If Yes, which bone(s) and when were you diagnosed? YES NO CONCUSSION HISTORY Have you ever had a concussion? If Yes, how many? Please give the date of your last concussion? How long were you out of athletics during your last concussion? Were you treated by a primary care physician for your last concussion? Were you required to see a specialist for your last concussion? Have you ever been knocked unconscious? How many times? Have you ever taken a computer based concussion test? IF YOUR LAST CONCUSSION WAS WITHIN THE PAST 6 MONTHS PLEASE PROVIDE WRITTEN CLEARANCE TO PARTICIPATE IN ATHLETICS FROM THE TREATING PHYSICIAN Athlete Agreement: (Initial) I fully understand that it is my responsibility to report ALL injuries or illnesses to the Athletic Training Staff at Meredith College. I understand that Saint Augustine s University will not be held responsible for the treatment, rehabilitation, etc. of any previous medical condition. Should there be any questions about previous conditions, I understand that I may be required to seek medical clearance to participate in my sport under my own insurance and financial accountability. Consent to treat: (Initial) I give the Saint Augustine s University Athletic Training Staff permission to treat me for any and all athletic injuries that occur while participating in NCAA Athletics during my career at Saint Augustine s University. I understand that referrals may be made to other medical professionals only by the Saint Augustine s University Athletic Training Staff, unless in the case of a medical emergency. I agree that all the information provided on this sheet is correct and complete to the best of my knowledge. I also acknowledge that I have read and understand Athlete Agreement and the Consent to Treat Statements Above. Athlete Signature: Date:

4 Primary Insurance Information Name: Student ID #: DOB: Please complete ONE of the following sections based on your Primary Insurance Through Parent s Employer My Own Private Plan Policy Holder: Policy Holder DOB: Employer: Employer Phone: Insurance Company: Policy ID: Policy Group Number: Claims Address: Claims Phone: Does this policy cover: Dental: Yes No Prescriptions: Yes No Policy Holder: Policy Holder DOB: Insurance Company: Policy ID: Policy Group Number: Claims Address: Claims Phone: Does this policy cover: Dental: Yes No Prescriptions: Yes No (Initial) I attest that I have insurance coverage under a current in force insurance policy for injuries that occur during my participation in intercollegiate athletics. I understand that it is my responsibility to notify the Saint Augustine s University Athletic Training Staff of any changes in coverage or expiration of coverage and update the information on file. (Initial) I understand that Saint Augustine University provides a secondary, injury only, insurance policy to all student-athletes and that this policy has limits and may not provide absolute coverage of all medical expenses due to injury. (Initial) I understand, and agree, that Saint Augustine s University will assume no responsibility for the payment of, authorization to pay, or medical expenses resulting from injuries that occur while participating in intercollegiate athletics at Saint Augustine s University. Signature of Primary Insurance Policy Holder Date Signature of Student Athlete Date

5 Sports Medicine Fiscal Responsibility of Student-Athletes Saint Augustine s University provides a secondary athletic insurance coverage for student-athletes. This secondary insurance coverage works best when used with a primary insurance coverage. A primary insurance policy is one that is provided by you or your parents or legal guardian. In the event that an injury occurs and either insurance type is applied to medical care for this injury, there could be some degree of financial responsibility on the student-athlete s part. This financial responsibility will be much less in the presence of a primary and a secondary insurance. In the case that only the schools athletic insurance policy is solely used, you will receive a bill from the medical provider and it will be your responsibility to pay that bill. I understand that I may be responsible financially for any medical care received while participating in any athletic program at Saint Augustine s University. Print Name: Signature: Date:

6 Saint Augustine s University Sports Medicine Release of Information Authorization The privacy of your medical information is protected by federal and state law. Except under certain circumstances, your medical information will not be disclosed without your consent. Saint Augustine s University is committed to maintaining the privacy of your medical information described below. The Department of Athletic Training (DAT) provides health care services to you as a student-athlete. DAT shares pertinent information about your condition with any outside provider whose assistance is necessary for further treatment (i.e. medical equipment vendors, specialists, surgeons, etc.) DAT provides appropriate information to your insurance company for payment to medical providers for the treatment provided to you. This type of sharing of medical information is common to most health care providers and may be a condition of treatment. Because you are a student-athlete, we also need your consent to share pertinent medical information within the Department of Athletics, as described below. Information on your condition may be provided to athletic trainers to share with your coach in order to make informed decisions about your return to your sport. DAT may provide some of your medical information to the Department of Athletics for required disclosure to external governing bodies, such as the NCAA or the CIAA. DAT may communicate general information about your injuries and status to the Sport Information Director (SID). The SID, in turn, may disclose general status information to various media outlets (newspaper, magazines, television, etc.). DAT may communicate pertinent medical information to necessary university officials so that professors will understand how an injury will impact academic performance. DAT will not share your medical information with professional agents, professional teams or leagues, attorneys, or unrelated third parties without your independently provided written consent, separate from this document. I understand the information provided above describing the types of disclosures of my medical information by the Department of Athletic Training and the Department of Athletics (including the Sports Information Director) at Saint Augustine s University. I consent to my medical information being shared in the manner. This consent expires 365 days from the date of my signature below, but I have the right to revoke it in writing at any time by sending written notification to the Department of Athletic Training. I understand that a revocation is not effective to the extent action has already been taken in reliance of this consent. Print Name: Signature: Date: SS# Student ID #:

7 Sports Medicine Responsibility Waiver and Assumption of Risk As an athlete, student, or staff member at Saint Augustine s University, I agree that Saint Augustine s University and/or the athletic department and their staff, coaches, athletic trainers, or employees will not be held responsible for any accidents or loss of personal property, however caused, and agree to release the university from all claims or damage which may arise as a result of such accident or loss. It is further agreed that all risks attendant to watching and/or participating in any athletics at Saint Augustine s University are assumed by the student athlete and his/her parents or guardian and that this assumption is acknowledged, approved by their signatures below. Print Name: Signature: Date:

8 Concussion Statement Form A concussion is a mild traumatic brain injury that occurs when a blow or jolt to the head disrupts the normal functioning of the brain. Signs/Symptoms-headache, neck pain, nausea, lack of energy and/or physically and mentally tired, dizziness, light-headiness, loss of balance, blurred or doubled vision, sensitivity to light, sensitivity to sounds, ringing in the ears, loss of taste or smell, and change in sleep patterns. Any student athlete that exhibits a head injury and exhibits any of the above signs or symptoms will be evaluate immediately by the athletic training staff. Any student athlete that obtains a concussion during athletic activity will not be allowed to return to competition for the remainder of that particular day. When the injury is evaluated the student athlete will be made to either see the team physician/ecsu medical doctor located at the infirmary. The team physician will be used to decide if any further medical attention is needed. I understand the above statements and will report any injury/concussion related signs/symptoms to the athletic training staff immediately. Print name Date Signature