TEXAS A&M UNIVERSITY-TEXARKANA DEPARTMENT OF ATHLETICS

Transcription

1 TEXAS A&M UNIVERSITY-TEXARKANA DEPARTMENT OF ATHLETICS MEDICAL INSURANCE AND INFORMATION FORM The following information and authorization must be completed, signed and returned prior to participation in athletics. ATHLETE S INFORMATION Name Sport SSN Date of Birth Gender HEALTH INSURANCE INFORMATION Primary Policy Holder s Name Insurance Company Name Member ID # Group # Claims Address Claims Phone # Effective Date Deductible Amount Do you have a co-pay? Yes No Policy Holder s Employer Address of Employer Does the policy cover athletic related injuries? Yes No Are you/your son/daughter covered by the above policy? Yes No Do you/your son/daughter have a prescription plan? Yes No Prescription Plan Name (if different from above) BIN # Member # If uninsured, please initial agreeing to provide any information requested by the Athletic Department.

2 PARENT/GUARDIAN INFORMATION Please choose one: Guardian Father Mother Name Date of Birth Address Cell Phone Alternate Phone Employer Please choose one: Guardian Father Mother Name Date of Birth Address Cell Phone Alternate Phone Employer AUTHORIZATION I hereby authorize a claim to be filed on my behalf under the above insurance policies in the event an athletic injury is sustained by me/my son/daughter. I hereby authorize Texas A&M University-Texarkana Athletic Department to release the above information as well as release any medical information needed to process a claim on their behalf for my/son/daughter s medical expenses with my insurance company. I hereby authorize the payment of medical benefits, by my insurance company, be made to the physicians or supplier for services rendered. A photocopy of this authorization shall be considered as effective and valid as the original. Insurance Holder s Signature Date Please enclose a copy of the front and back of your health insurance card(s), prescription card(s), and dental card(s).

3 STATEMENT OF POTENTIAL INJURY DUE TO PARTICIPATION IN INTERCOLLEGIATE ATHLETICS The purpose of this statement is to inform each parent/guardian/student-athlete of the risk of injury while participating in intercollegiate sports practice and competition. The extent of such injuries may be irreversible and in some cases may prove to be crippling, reducing their ability to earn a living. There is even a small chance that an injury may prove to be fatal. Athletes participating in sports such as football, soccer, and basketball (classified as collision sports) will experience many types of physical contact. Texas A&M University-Texarkana provides protective equipment. However, equipment and instruction cannot prevent all serious injuries that may result. Efforts will be made to protect the student-athlete from injury. Athletes must, however, share the responsibility and recognize the necessity for following the rules and regulations designed to make intercollegiate sports practice and competition safer and less hazardous. There are other injuries not included, but here is a non-exclusive list of injuries a student-athlete could sustain by participating in athletics at Texas A&M University-Texarkana: head injuries resulting in coma, brain damage and/or death; spine injuries resulting in quadriplegia, paraplegia, and/or death; strains resulting in completely torn, partially torn, and/or stretched muscles or tendons; sprains resulting in completely torn, partially torn, and/or stretched ligaments; lacerations, abrasions and other flesh wounds that could result in infection; contusions; internal organ damage; loss of limb or vital organ of the body; cartilage damage in the joints of the body. By signing this document, you recognize the student-athlete assumes the risks associated with their participation in athletics and that they have been warned of the hazards inherent in sports competition. Please discuss the risks with the student-athlete before signing this form. If you have any questions, please contact the Director of Athletics to discuss your concerns. I have read the above statement and I am aware of the inherent risks involved in athletic related activities at Texas A&M University- Texarkana. Signature of Parent or Guardian Date Signature of Student-Athlete Date

4 CONSENT FOR MEDICAL TREATMENT & MEDICAL INFORMATION RELEASE Permission is hereby granted to the team/attending physician(s) and/or athletic trainer(s) to proceed with any needed medical or emergency treatment, diagnostic test, examination, rehabilitation and immunizations for the above named student-athlete. Permission is also granted to disclose any medical or personal insurance information on above studentathlete amongst any pertinent medical personnel, who may include: the Texas A&M University-Texarkana Athletic Training Staff, Athletic Administration, coaches, insurance/claims personnel, hospitals, doctor s staff, etc. In the event of serious injury/illness, the need for major surgery, or significant accidental injury, it is understood that an attempt will be made by the team/attending physician or athletic trainer to contact one of the listed contacts in the most expeditious manner possible. If the team/attending physician or athletic trainer is unable to contact the family or emergency contact, the treatment necessary for the best interest of the student-athlete may be given. Also, the medical/health insurance that covers the student-athlete will be used as the primary insurance. Signature of Parent or Guardian Date Signature of Student-Athlete Date

5 INJURY/ILLNESS AGREEMENT I understand that I must refrain from practice or play while ill or injured if so determined by the Texas A&M University- Texarkana team physician and/or staff athletic trainer. The return to play decision will be determined by the Texas A&M University-Texarkana team physician and/or staff athletic trainer. The Texas A&M University-Texarkana sports medicine staff with the recommendation of the team physician has the final authority in determining if the student-athlete is physically fit to participate in athletics at Texas A&M University-Texarkana. I am required to attend all treatment, rehabilitation and doctor appointments deemed necessary by the Texas A&M University-Texarkana sports medicine team. I accept the responsibility for reporting all injuries and illnesses that occur to me to institutional medical staff, especially all signs and symptoms of concussions. Signature of Parent or Guardian Date Signature of Student-Athlete Date

6 STUDENT-ATHLETE FACT SHEET Name Date PERMANENT PARENT/GUARDIAN ADDRESS Address City State Zip Home Phone COLLEGE ADDRESS (Dorm & Room or Apartment) Address City State Zip Cell Phone Eligibility Status Gender SSN DOB Student ID EMERGENCY CONTACT INFORMATION In case of emergency, please contact (other than parent, ex. Grandparent, uncle, etc.) Name Relationship Phone Please list all allergies. Please list all medications including inhalers and epipens.

7 HEALTH HISTORY This form is for your benefit. You must disclose all injuries or problems whether you consider it to have been serious or minor. Name Date Sport HAVE YOU EVER HAD OR CURRENTLY HAVE ANY OF THE FOLLOWING ILLNESS/MEDICAL ISSUE? PLEASE CHECK YES OR NO FOR EACH ITEM. ILLNESS/MEDICAL ISSUE YES NO ILLNESS/MEDICAL ISSUE YES NO Scarlet Fever, Erysipelas? Kidney Stones? Diphtheria? Skin Trouble? Rheumatic Fever? Venereal Disease? Mumps? Bone, Joint, or Other Deformity? Whooping Cough? Car, Train, Sea, Air Sickness? Measles? Loss of Memory or Amnesia? Frequent or Sever Headaches? Any Drug or Narcotic Habit? Eye, Ear, Nose, or Throat Trouble? Mononucleosis? Severe Tooth or Gum Trouble? Gout? Sinusitis? Diabetes? Tuberculosis? Tonsillitis? Asthma? Pneumonia? Chronic Cough? Worn Glasses or Contacts? Frequent Indigestion? Worn Hearing Aids? Intestinal, Liver Trouble? Coughed Up Blood? Gall Bladder Trouble, Gallstones? Bled Excessively After Tooth Extraction? Stomach Trouble (Ulcers?) Been Denied Life Insurance? Sickle Cell Trait Applied For or Collected Workmen s Compensation? Excessive Drinking Habit? Been Rejected for Military Service because of Physical, Mental, or Other Reasons? Tumor, Growth, Cyst, Cancer? Been Discharged from Military Service because of Physical, Mental, or Other Reasons? Appendicitis? Entered Litigation or Claimed Damage because of Injury to or effect on your health? Piles or Rectal Disease? Denied or restricted playing sports by a physician? Frequent or Painful Urination? Each item that you checked Yes to above must be fully explained below. PROCEDURE/HOSPITALIZATION DOCTOR DATE Please list any other MEDICAL ILLNESSES or anything else you would like to speak to a doctor about.

8 Have you any surgeries? Yes No If yes, please list below. SURGERY DOCTOR DATE Have you been advised to have a surgery? Yes No If yes, please list below. SURGERY DOCTOR Please list any medication(s) you are currently taking, including inhalers and/or epipens. Please list any known DRUG/FOOD/INSECT allergies. Have you ever been diagnosed with a Heart Murmur or Weak/Enlarged Heart? Yes No If yes, please explain and list what tests were performed? PLEASE CHECK YES OR NO IF YOU HAVE YOU EVER EXPERIENCED ANY OF THE FOLLOWING SYMPTOMS WITH EXERCISE. MEDICAL ISSUE YES NO MEDICAL ISSUE YES NO Chest Pain Shortness of Breath Dizziness Fainting Rash / Hives Coughing / Wheezing / Trouble Breathing Heat Related Illness Tiring more quickly than your friends If you answered Yes to any of the medical issues listed above, please explain below. Do you have a family member(s) that have died of heart problems or unexplained reasons before the age of 50? Yes No If yes, please explain: Have you ever had a concussion? Yes No Have you ever had a seizure? Yes No Do you have any non-functioning or missing any of your paired organs? (ex. Kidney, Eye, Testicle) Yes No Have you ever been suspected of having an eating disorder? Yes No Please list any medical issues or illness in your family history. I certify that I have made full and complete written disclosure of all past and present injuries or problems as required. I understand that failure to do so may result in loss of playing time, eligibility, and possible scholarship reduction. I understand that any costs that result in my failure to report my medical history may be my responsibility. Printed Name Date Signature Witness

9 PHYSICIAN PHYSICAL EXAM FORM Name Date Student ID DOB Sport Eye Vision Corrected? Yes No If yes, do you wear: Glasses OR Contacts Height Weight BP / Temp GENERAL APPEARANCE NORMAL ABNORMAL FINIDNGS Skin Eye Ear Nose Throat Teeth Lungs Heart Chest Liver Spleen Spine Joints Neck Shoulders Elbows Wrists Hands Hips Knees Ankles Feet Neurological Hernia Genitalia (Male Only) Clearance? Clearance No Clearance Clearance Held Limited Clearance Further Evaluation Required? Yes No Recommendations/Comments PHYSICAN INFORMATION Printed Name Signature

10 DRUG SCREENING RELEASE I understand that the Office of Athletics at Texas A&M University-Texarkana has a program for drug testing, education, and assistance to help ensure the health, safety, and welfare of its student athletes and to ensure the continued integrity of Texas A&M-Texarkana s intercollegiate athletic program. I agree to submit to drug testing and understand that non-compliance with the Office of Athletics Drug Education, Testing, and Counseling Program and Procedures will be a breach of this agreement which permits the athletic department to remove me from participation in the Athletic Program. Printed Name Date Signature Sport NOTE: Student athletes who are taking drugs pursuant to a prescription are required to register this fact with the Athletic Trainer in writing and to supply such additional information as may be requested by the Athletic Trainer. This information helps to determine the physical eligibility of a student to participate in the intercollegiate athletic program. Further, it is possible that some prescription drugs may result in a positive test in this program. This information will be kept confidential pursuant to the guidelines of this policy. Please list any drugs you are currently taking below.

11 PARENT/GUARDIAN INFORMED CONSENT AND RELEASE OF LIABILITY STATEMENT I,, as the parent/legal guardian of Parent/Guardian s Printed Name, herby acknowledge that I have been fully Student-Athlete s Printed Name advised on Texas A&M University-Texarkana Department of Athletics Drug Education, Testing, and Counseling Program and Procedures. I understand that as a condition of my son/daughter s participation in intercollegiate athletics at Texas A&M-Texarkana, he/she must agree to undergo, during the academic year, one or more standardized urinalysis or any other recognized test and that my son/daughter has executed the Drug Screening Release on the previous page. I hereby give my permission to the Office of Athletics at Texas A&M-Texarkana to conduct, with respect to my son/daughter, the standardized urinalysis or any other recognized test described in the Athletics Drug Education, Testing, and Counseling Program and Procedures. Signature Date

12 TEXAS A&M UNIVERSITY-TEXARKANA DEPARTMENT OF ATHLETICS RELEASE AND INDEMNITY FORM I,, understand and agree that the official Student-Athlete s Printed Name activities of the Office of Athletics of Texas A&M University-Texarkana (A&M-Texarkana) of which I am a student athlete, beginning and continuing with all subsequent activities as officially sponsored by Semester Month and Year A&M-Texarkana, involve certain known risks, including by not limited to, transportation accidents, personal injuries, and loss or destruction of my property. I understand and agree that A&M-Texarkana cannot be expected to control all of said risks. In consideration of the benefits I will receive through my participation in the activities of, I hereby expressly and knowingly RELEASE TAMUS, ITS Sport OFFICERS, AGENTS, VOLUNTEERS, AND EMPLOYEES FROM ANY AND ALL CLAIMS AND CAUSES OF ACTION I MAY HAVE FOR PROPERTY DAMAGE, PERSONAL INJURY OR DEATH SUSTAINED BY ME ARISING OUT OF ANY TRAVEL OR ACTIVITY CONDUCTED BY, OR UNDER THE AUSPICES OF TAMU-T AND/OR THE DEPARTMENT OF ATHLETICS, WHETHER CAUSED BY MY OWN NEGLIGENCE OR THE NEGLIGENCE OF TAMU-T, ITS OFFICERS, AGENTS, VOLUNTEERS, AND EMPLOYEES. I hereby give my consent for any medical treatment that may be required during my participation with the understanding that the cost of any such treatment will be my responsibility. Further, I voluntarily and knowingly agree to HOLD HARMLESS, PROTECT, AND INDEMNIFY TAMU-T, its officers, agents, volunteers, and employees, against and from any and all claims, demands, or causes of action for property damage, personal injury or death, including defense costs and attorney s fees, arising out of my participation in the activities of the Department of Athletics, REGARDLESS OF WHETHER SUCH DAMAGES, INJURY, OR DEATH ARE CAUSED BY MY OWN NEGLIGENCE, OR BY THE NEGLIGENCE OF TAMU-T, ITS OFFICERS, AGENTS, VOLUNTEERS, AND EMPLOYEES. A&M-Texarkana shall notify me promptly in writing of any claim or action brought against it in connection with my participation in these activities. Upon such notification, I or my representative shall promptly take over and defend any such claim or action. I HAVE READ AND UNDERSTOOD THIS DOCUMENT, AND MY SIGNATURE EVIDENCES MY INTENT TO BE BOUND BY ITS TERMS. Printed Name Student ID# Address Cell Phone Date of Birth Signature Date Parent/Guardian Signature (required if student under 18)