ALL PAPERWORK MUST BE COMPLETED AND SUBMITTED BY AUGUST 1st FOR ATHLETE TO BE ELIGIBLE FOR PARTICIPATION.

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1 MISSOURI VALLEY COLLEGE SPORTS MEDICINE POLICIES AND PROCEDURES Student Athlete Name: Sport: Please review all of the forms in this packet. Each of the forms contains information important to the student athlete. Please make sure to completely fill out online, if you print and fill out, please make sure to sign and date each form in blue or black ink. Please return forms to MVC Athletic Training Room in Burns Gym or completed forms to If you send them to any other department, there is no guarantee that we will receive them. Please review the forms for completeness. Incomplete forms or information found to be incomplete are unacceptable. Save a copy for your own records if you are sending the original packet. Student athletes will not be allowed to practice or compete until all of the information is provided. MISSOURI VALLEY COLLEGE PARTICIPATION REQUIREMENTS Missouri Valley College requires all student athletes to carry private health care insurance. Student athletes must provide proof of health insurance with Missouri Valley College Athletic Training or he/she WILL NOT be eligible for participation. If a student athlete s health insurance changes throughout the year it is his/her responsibility to inform the Missouri Valley College Athletic Training department of these changes and have a copy of the new insurance information. All participants must also receive a pre-participation physical, prior to ANY sport activity including: weight lifting, conditioning, practices and competitions that takes place at any time during preseason, in season or post-season. Physicals are good for one calendar year, from date of exam. All physicals must be current and in good standing for the entire school year. Missouri Valley College Sports Medicine Staff Matt Long ATC, LAT Head Athletic Trainer Sierra Fultz, ATC, LAT Richelle Perkins, ATC, LAT Jake Bellon ATC, LAT Vince Fedorowhich, ATC, LAT Missouri Valley College Attn: Athletic Training 500 E. College Marshall MO athletictraining@moval.edu Office: Fax: (Attn: Athletic Training) ALL PAPERWORK MUST BE COMPLETED AND SUBMITTED BY AUGUST 1st FOR ATHLETE TO BE ELIGIBLE FOR PARTICIPATION.

2 MVC INSURANCE NOTIFICATION As the parent/legal guardian/participant, I understand that Missouri Valley College DOES NOT carry health insurance for their student-athletes. Therefore, I realize that ALL medical bills incurred as a result of my son/daughter participating in athletics at MVC are my responsibility. I realize that it is mandatory for my son/daughter to be adequately covered by health insurance while participating in athletics at MVC. This health insurance policy that I have chosen covers my son/daughter for accidents that occur from sports participation (broken bones, torn ligaments, dislocation, etc...). If I cancel or have my medical insurance discontinued for any reason, either voluntarily or involuntarily, I realize that all medical bills that may accumulate are still my responsibility and not the responsibility of MVC or its employees. It is the responsibility of the Parent/Guardian/Participant to determine if the insurance the student-athlete is currently covered under is adequate for athletic participation and will cover the student-athlete in the state of Missouri at Missouri Valley College. Should the insurance not cover athletics or in the state of Missouri all medical bills will be the responsibility of the parent/guardian/participant. The student-athlete must be covered during all participation of any type of sport/team related activity throughout the entire 10 month school year (Aug 1st-May31st). This includes all pre-season, in-season, post-season and off-season activities that take place during the school year and season of the sport. If the student-athlete is not covered during any of this time, they will not be allowed to participate. Any injury incurred will not be the financial responsibility of Missouri Valley College. Athlete or Parent/Legal Guardian Signature : Date : MISSOURI VALLEY COLLEGE DRUG POLICY NOTIFICATION AND ACKNOWLEDGEMENT By signing this form, you certify that you agree to be tested for drugs at any time, for any reason during the academic school year. You agree to allow Missouri Valley College (MVC) to test you for the banned drugs that are listed in the MVC and/or NAIA Banned Drug List. This means that you agree to allow MVC to test on a year round basis for the banned drugs appearing on the MVC and/or NAIA Banned Drug List, this list is in the student-athlete handbook. Additionally, you also agree to be tested for anabolic steroids, elevated levels of HGH, diuretics, urine manipulators, and any drug masking agent. You understand that if you test positive, you will be responsible for the payment of the drug testing fee. If you test negative, the institution/team/sport will assume the cost of the fees. The MVC drug policy can be found in the student athlete handbook on page I have read and understand the MVC drug policy outlined in the Student Athlete Handbook. Athlete Signature : Date :

3 MISSOURI VALLEY COLLEGE STUDENT-ATHLETE INFORMATION FORM Please complete ALL of the following information Student Athlete Information Last Name: First Name: Middle Initial: Date of Birth: Sport(s): SS#: Address: Phone Number: Allergies: Other Medical Conditions:(asthma, diabetes, heart condition, sickle cell status, etc) Medications: Emergency Contact Information Last Name: Primary Phone Number: First Name: Secondary Phone Number: Home Address: City/State/Zip: Insurance Information Primary Policy Holder: Policy Holder s SS#: Name of Insurance Company: Group and/or Policy Number: Identification Number: Insurance Company Address: City/State/Zip: PLEASE PROVIDE A COPY OF YOUR INSURANCE CARD (front and back) If your insurance coverage changes or terminates during the year please contact us with the updated information immediately and a copy of the new insurance card. Affidavit : I verify that the above statement regarding insurance is accurate and complete. Athlete or Parent/Legal Guardian Signature : Date :

4 MISSOURI VALLEY COLLEGE RETURNING ATHLETE YEARLY MEDICAL HISTORY APPRAISAL Today s Date: Sport: Athlete Information Athlete s Full Name: Social Security #: Date of Birth: Local Address: Permanent Address: City/State Zip: Home Phone #: Cell Phone #: Personal Medical History In the past 12 months, have you been restricted from participating in physical activity? YES, Please explain below NO Date(s): Reason(s): Do you have any allergies to medications, pollens, foods, or stinging insects? YES, Please explain below NO Specify: Specify: Explain Reaction: Explain Reaction: Are you currently taking and Prescribed or Over the Counter medications? (Please include birth control, insulin, allergy shots/pills, asthma inhalers, anti-inflammatories including aspirin, medications for ADD/ADHD, antidepressants, vitamins, nutritional supplements) Name: Dosage: Reason: Name: Dosage: Reason: Since beginning eligibility as a student athlete at Missouri Valley College have you had any: Serious Illness, Disease, Infection YES NO Please Specify: Operation or Hospitalization YES NO Please Specify: Mental Illness YES NO Please Specify: Accident - Non-sport related YES NO Please Specify: In the past 12 months Have you been examined by a physician other than a MVC team physician YES NO Please Specify: Have you been outside of the US YES NO Please Specify: Have you had any immediate relative die suddenly YES NO Please Specify: Have you experienced dizziness, lightheadedness, passing out or fainting, chest pain, discomfort, tightness in chest, difficulty breathing, wheezing before/after exercise YES NO Please Specify: Have you experienced an injury to head/neck YES NO Please Specify: Have you had a significant weight loss or gain YES NO Please Specify:

5 ORTHOPEDIC YEARLY MEDICAL HISTORY Please indicate if you have sustained any injuries to said body parts in the past 12 months. HEAD YES NO Please specify: NECK SHOULDER ARM ELBOW FOREARM WRIST HAND FINGERS CHEST SPINE ABDOMEN PELVIS HIP THIGH KNEE LOWER LEG ANKLE FOOT TOES If you have any additional conditions, problems, or comments that have not been addressed thoroughly in the above questionnaire, please use the space below to inform us so that we may be better able to serve you with our medical care. This form will be reviewed by the Missouri Valley College Team Physicians and the Missouri Valley College Sports Medicine Staff and placed in your permanent medical file at Missouri Valley College. By signing below, I agree that all statements and answers in the above medical history questionnaire are true and complete to the best of my knowledge. I have no abnormality, limitation, or restriction not mentioned in this record. I understand that failure to disclose any or all medical problems and/or accurate medical history may result in forfeiture of my athletic aid, and relieves Missouri Valley college of any and all liability. Athlete or Parent/Legal Guardian Signature : Date :

6 MISSOURI VALLEY COLLEGE ASSUMPTION OF RISK STATEMENT I am aware that playing and/or practicing in any sport can be a dangerous activity involving MANY RISKS OF INJURY. I understand that the dangers and risks of playing and or practicing in any sport include, but are not limited to, death, serious head, neck, and spinal injuries which may result in complete or partial paralysis or brain damage, serious injury to virtually all bones, joints, ligaments, muscles, tendons, and other aspects of the musculoskeletal system, and serious injury or impairment to other aspects of my own (or my son/daughter) body, general health or well-being. Because of the dangers of participation in any sport, I recognize the importance of following the coach's instructions regarding playing techniques, training rules of the sport, other team rules, and to obey such instructions. All participants have the responsibility to help reduce the chance of injury by executing proper skill techniques of sport. Therefore, all student-athletes must obey all safety rules and regulations, report all physical problems to the athletic trainer and/or coach, follow a proper conditioning program, and inspect personal protective equipment daily. AFTER READING/PRINTING FORM PLEASE INITIAL EACH OF THE FOLLOWING STATEMENTS AND SIGN TO SHOW THAT THE STATEMENTS HAVE BEEN READ, UNDERSTOOD, AND APPROVED. I consent to have my self/son/daughter represent the Missouri Valley College in Approved activities except those activities excluded by the examining team physicians. In the event of any injury or illness, including an emergency situation, requiring medical attention, I grant permission for any treatment deemed necessary by the Sports Medicine Staff or attending physician and also authorize transfer of my self/son/daughter to a qualified medical facility. I agree not to hold the Missouri Valley College or anyone on its behalf responsible for any injury occurring to my self/son/daughter in the proper course of such athletic activities or travel. I acknowledge and accept that there are risks of physical injury involved in athletic participation which may result in permanent paralysis, mental disability, and death. I hereby voluntarily assume all risks associated with participation and agree to exonerate and save harmless Missouri Valley College and their agents, servants, and employees, the athletic staff of Missouri Valley College, the physicians and other practitioners of the healing arts treating my self/son/daughter from any and all liability claims, causes of action or demands of any kind and nature whatsoever which may arise by, or in connection with, my participation in any activities to the Missouri Valley College team in which my self/son/daughter is involved. Student-Athlete Signature : Date :

7 Parent/Legal Guardian Signature : Date : AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION I,, hereby release my medical information to the following: Parents/Legal Guardians/Spouse Coaches/Athletic Staff Teammates Media Professional teams and their representatives MVC Student Athletic Trainers (All have signed confidentiality agreements) HAAC/NAIA MVC Medical Facilities (Counseling Center, Student Health Center) Other MVC Administration (as deemed necessary) I hereby authorize all members of the Missouri Valley Sports Medicine Staff, all Missouri Valley College Team Physicians, or any other physicians or health care professionals retained by them to release information, records, and reports regarding my medical history, medical status, record of injury and/or surgery, prognosis, diagnosis, record of serious illness, rehabilitation, and related personally identifiable health information to parties identified above. The information includes injuries or illnesses relevant to past, present, or future participation in athletics at Missouri Valley College. I understand that if the information being disclosed herein contains information regarding Athletic Department drug testing and or alcohol/drug abuse or treatment, psychiatric care, sexually transmitted diseases, AIDS or HIV, or Hepatitis B or C testing or results, I agree to their release. The reason for this disclosure is to advise the parties identified above of the nature, diagnosis, prognosis, or other treatment concerning my medical condition and injuries/illnesses sustained while I am a student-athlete. I understand that the individuals or entities receiving the information are not health care providers or health plans covered by federal privacy regulations, and that the information described above may be redisclosed publicly. I understand that Missouri Valley College will not receive compensation for its use/disclosure of the information. I may inspect or copy any information used/disclosed under this authorization and I am entitled to receive a copy of this authorization. I understand that I may revoke this authorization at any time by notifying in writing to the Head Athletic Trainer, but if I do, it will not have any effect on actions the university took in reliance on this authorization prior to receiving the revocation. This authorization expires six (6) years from the date it is signed. Student-Athlete Signature : Date : Parent/Legal Guardian Signature : Date :

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