NO PARTICIPATION UNTIL THIS ENTIRE PACKET IS COMPLETED AND TURNED INTO THE ATHLETIC OFFICE.

Transcription

1 NO PARTICIPATION UNTIL THIS ENTIRE PACKET IS COMPLETED AND TURNED INTO THE ATHLETIC OFFICE. Dear MVCC Student Athlete: In order to participate in Intercollegiate Athletics at Moraine Valley Community College you must provide the following: Official SIGNED & DATED Transcript from H.S. attended Official Transcripts from Any Other Colleges *Parent Insurance Information Form - This form is available on MVCC s website. *1 st Agency Health Information Form - This form is available on MVCC s website. *Student Waiver of Liability Form - This form is available on MVCC s website. *Physical Form- Dated - This form is available on MVCC s website. *Student Athlete Health Screening Form - This form is available on MVCC s website. Complete the information packet and return it to the Athletic Office located in our new Health Fitness & Recreation Building Room H120, no later than five days prior to tryouts. We look forward to having you as a student and athlete at Moraine Valley Community College. We are sure your athletic experience will be successful. Sincerely, William G. Finn Athletic Director, Moraine Valley Community College *These forms are available on MVCC s website.

2 First Agency, Inc West H Avenue Kalamazoo, MI AUTHORIZATION - To Permit Use and Disclosure of Health Information This Authorization was prepared by First Agency, Inc. for purposes of obtaining information necessary to process a claim for benefits. Upon presentation of the original or a photocopy of this signed Authorization, I authorize, without restriction (except psychotherapy notes), any licensed physician, medical professional, hospital or other medical-care institution, insurance support organization, pharmacy, governmental agency, insurance company, group policyholder, employer or benefit plan administrator to provide First Agency, Inc. or an agent, attorney, consumer reporting agency or independent administrator, acting on its behalf, all information concerning advice, care or treatment provided the patient, employee or deceased named below, including all information relating to, mental illness, use of drugs or use of alcohol. This Authorization also includes information provided to our health division for underwriting or claim servicing and information provided to any affiliated insurance company on previous applications. If this Authorization is for someone other than myself, that individual has given me the authority to act on his/her behalf as explained below. I understand that I have the right to revoke this Authorization, in writing, at any time by sending written notification to my agent or to us at the above address. I understand that a revocation will not be effective to the extent we have relied on the use or disclosure of the protected health information or if my Authorization was obtained as a condition to determine my eligibility for benefits. Revocation requests must be sent in writing to the attention of the Claims Supervisor. I understand that First Agency, Inc. may condition payment of a claim upon my signing this authorization, if the disclosure of information is necessary to determine the level or validity of the claim payment. I also understand, once information is disclosed to us pursuant to this

3 Authorization, the information will remain protected by First Agency, Inc. in accordance with federal or state law. I understand that I or my authorized representative is entitled to receive a copy of this authorization upon request. This Authorization is valid from the date signed for the duration of the claim. Name of Claimant (please print) Name of Authorized Representative, or Next of Kin (please print) Signature of Claimant (if claimant is 18 or older) Date Signature of Authorized Representative of Next of Kin Date SIGN AND DATE Relationship of Authorized Representative or Next of Kin to Claimant First Agency, Inc West H Avenue PARENT/GUARDIAN/STUDENT INFORMATION FORM Kalamazoo, MI RETURN FORM WHEN COMPLETE TO Name of College/University Moraine Valley Community College Attention Bill Finn, Athletic Director

4 This form is to be completed by the Address 9000 College Parkway Parents, Guardians or Student City Palos Hills State IL Zip Note: Complete all blanks on this form. Failure to complete all blanks will result in claims processing delays. If information is not applicable, indicate the reason it is not (e.g., deceased, divorced, unknown). Name of Athlete Cell Phone Address Sport Date of Birth City State Zip COPY OF INSURANCE CARD OR MOTHER/FATHER/GUARDIAN INFORMATION Parent s Name Date of Birth Address Employer Address Telephone ( ) Medical Insurance Company or Plan

5 Address POLICY NUMBER TELEPHONE ( ) Is this plan an HMO or PPO? Yes No Is pre-authorization required to obtain treatment? Yes No Is a second opinion required before surgery? Yes No ATHLETIC PREPARTICIPATION INFORMATION STUDENT INFORMATION Name Sport Birthdate Home Address City/State/Zip Home Phone Cell Phone

6 Personal PARENT OR GUARDIAN ADDRESS IF OTHER THAN ABOVE Name Cell Phone ( ) - EDUCATIONAL HISTORY High School attended Graduation Date Previous College(s) attended Dates: from to If you were not enrolled in college after high school graduation, please let us know what you were doing i.e., working, unemployed, internship, etc. YOU MUST SUBMIT TO THE MVCC ATHLETIC DEPT. OFFICIAL TRANSCRIPTS FROM ANY COLLEGE OR UNIVERSITY ATTENDED TO THE MVCC ATHLETIC DEPT BEFORE ANY PRACTICE OR PARTICIPATION. STUDENT SIGNATURE I give my permission for Moraine Valley Community College to release my academic transcripts to other colleges, universities or other institutions.

7 Student Signature SECOND YEAR ELIGIBILITY I understand that to be eligible to compete in a second season of any sport I must have completed at least 24 credits with passing grades, and obtained a 2.0 GPA or higher. Student Signature Date

8 STUDENT/PARTICIPANT WAIVER OF LIABILITY/HOLD HARMLESS AGREEMENT & STUDENT OFF-CAMPUS FIELD TRIP AGREEMENT FORM This event offers a unique opportunity to gain field experience for an extended period of time. The program relies on the cooperation and good will of various private businesses, individuals, organizations and government entities. Because of our obligations to those persons and agencies and because we understandably cannot assume responsibility for the carious persons and agencies, which are in different ways connected with our programs, we ask that you adhere to the following terms and conditions of participation. Your dated signature indicates that you understand and agree to those terms and conditions. Student Name (Please Print) Age Address City Zip Home Phone ( ) Trip to INTERCOLLEGIATE SPORTS Date of Trips AUGUST 1, 2018, TO JUNE 30, 2019 Emergency Contact Name Contact Number (s) Home ( ) Cell ( ) ** I have read the terms of this hold agreement and I understand and agree to the terms/conditions of this agreement.** Name (Please Print) Signature of Participant or Parent (If a minor) Date In order to safeguard my physical health and safety and that of my fellow students, and to protect the good name and reputation of MORAINE VALLEY COMMUNITY COLLEGE while on any field trip, I agree to: Observe all public laws and ordinances, including traffic laws as well as the usages and customs of good citizenship, decorum, and courtesy while observing all rules of the host institution or agency that apply to visitor or the general public. The Student Life Office or the Academic Dean s office at Moraine Valley Community College reserves the right to disallow, discontinue and cancel any participant s trip with reasonable cause. Students attending off-campus trips must attend and be on time for all aspects of the program (workshops, retreats, meetings, etc). In addition, it is understood that I am totally responsible for my conduct on the trip and in no way is the college or any college personnel liable for the effects of my conduct on the trip. I HAVE READ AND UNDERSTAND THE RULES OF THIS FORM, AND I AGREE TO ABIDE BY THEM. (If student is under 18 years of age, parental approval is necessary). Date: Student signature (parent if minor)

9 THIS IS NOT A PHYSICAL FAMILY HISTORY PLEASE ANSWER ALL QUESTIONS (Check appropriate Yes or No answers.) Yes No Yes No Yes Asthma, Hives, Hayfever Migraine Heart Attack Arthritis Sickle Cell/Anemia Strokes Seizures/Convulsions High Blood Pressure Epilepsy Diabetes Explain "Yes" Answers Knee Problems Allergies? Yes No Yes No Yes Bee Sting Penicillin Codeine Adhesive Tape Morphine Aspirin Tetanus Mycins Any other allergies? Do you wear? (Please circle and explain.) Eyeglasses Contact Lenses Dentures Dental Braces Bridgework False Eye Explain SYSTEMS HISTORY (Check appropriate Yes or No answers.) Yes No Yes PLEASE ANSWER ALL QUESTI No Yes Irregular Pulse Jaundice Heart Murmurs Mononucleosis Enlarged Liver Hernia Menstrual Disorder One Testicle Ulcers Enlarged Spleen Thyroid Disease Heat Illness Tuberculosis One Working Ovary Hospitalized One Kidney Explain "Yes" answers INJURY HISTORY (Check appropriate Yes or No answers.) Yes No Yes No Yes Pinched Nerve Separated Shoulder R/L Knee Injury R/L Skull Fracture Foot Injury R/L Ankle Injury R/L Concussion Head Injury Hand Injury R/L Back Injury Neck Injury Broken Bone Explain "Yes" Answers MORAINE VALLEY COMMUNITY COLLEGE PERSONAL MEDICAL HISTORY (Check appropriate Yes or No answers.) Are you currently taking medication ( please circle) YES NO Explain if YES ATHLETE'S SIGNATURE DATE

10 Pre-participation Physical Evaluation No practice until you have a physical You can go to Walgreens/CVS/etc. PHYSICAL EXAMINATION BY A PHYSICIAN Name Date of birth Height Weight %Body fat (optional) Blood Pressure Medical Normal Abnormal findings Initials Appearance Eyes/ears/nose/throat Lymph nodes Heart Pulses Lungs Abdomen Genitalia (males only) Skin Clearance Cleared Cleared after completing evaluation/rehabilitation for: Not cleared for: Reason:

11 Recommendations: Name of physician (print/type) Date: Signature of physician. M.D. or D.O.