University of Wisconsin La Crosse Eagles

Transcription

1 Dear Student-Athlete and Parents/Guardians: The University of Wisconsin-La Crosse is pleased to have you join us as an Eagle Student Athlete. The Athletic Training Services staff looks forward to working with you as you arrive on campus and prepare to begin your collegiate athletic career. Enclosed is the Incoming Student Athlete Pre-Participation Packet. Please review this information carefully. All forms are required prior to initial participation in your sport(s). The forms must be fully completed and returned no later than August 1 st. Delay in the return or errors in the completion of this packet may cause you to not be able to participate on your sport(s) starting date. If you need to provide additional information, please attach a separate sheet. An electronic version of this packet is being prepared; however it is not presently ready for release. All incoming student-athletes are required to obtain cardiac testing within the initial months of their arrival on campus. This will be done at UWL and requires no prior effort. Please see enclosed memo for more information. Please Note: On several of the forms, if the Student-Athlete is under 18 years of age, a Parent/Guardian must also sign the form in addition to the Student-Athlete s Signature in the signature space provided. Student-Athletes will not be allowed to practice or participate in any sport-related activities until all off the enclosed paperwork is returned and insurance coverage has been verified by UW-La Crosse staff. Intentional falsification of information may be grounds for immediate disqualification and/or disciplinary action up to and including removal from the athletics program. Return packet to: University of Wisconsin-La Crosse Director of Athletic Training Services 10 Mitchell Hall 1725 State St. La Crosse, WI Or send via fax to: If you have any questions concerning University of Wisconsin-La Crosse policies, NCAA rules and/or policies, or any of the required information requested on the forms, please contact us at (608) Joel Luedke MSe, ATC, LAT, CES Director of Athletic Training Enclosures: Form A: Physical Examination Form Form B: Health History Questionnaire Form C: Insurance Information Form D: Acknowledgement of Insurance Requirements Form E: HIPAA Acknowledgement & Waiver Form F: Authorization/Consent for Disclosure of Protected Health Information for NCAA Related Purposes Form G: Sickle Cell Waiver Form Form H: NCAA Concussion Compliance Statement Form I: Student-Athlete Consent for Medical Treatment & Catastrophic Injury Assumption of Risk

2 PLEASE TYPE OR PRINT LEGIBLY: University of Wisconsin La Crosse Form A: Physical Examination Form Athlete s Name Sport(s) Date of Birth Sex M F Other Parent s Name Parent s Phone Parent s Address Insurance Company Group # Policy # Personal Health Information The NCAA highly recommends that you know your Sickle Cell Trait status and may, in the future, mandate testing if you do not know. Please consider testing now and reporting your status. Sickle cell trait status? (circle one) Positive Negative Unknown *Please provide sickle cell results if available. If unknown, do you plan to get tested to find out? (circle one) Yes No List any medications you are currently taking including birth control and over the counter medications or dietary/performance supplements: List any allergies: Check and record date of any illness/condition you have or had in the last 5 years: Epilepsy Frost Bite Heat Illness Asthma Hay Fever Surgery Concussions Mononucleosis Hospitalization Diabetes Heart Problems Tuberculosis Explain any current illness and/or medical limitations: Do any of the following apply to you?: Y N High Blood Pressure Y N Use of Orthotics Y N Scoliosis Y N Heart Problems Y N Wear Contacts/glasses Y N Unpaired Organ (i.e. 1 kidney) Y N Passed out during sports/exercise Y N Family history of death before 50 Y N Are your periods regular? Y N Seizures Y N Migraines Y N Asthma Y N Hearing Aid Y N Other Explain any YES answers:

3 Physical Examination (To be completed by a MD, DO, NP, PA) Athlete s Name Height Weight Heart Rate Sport(s) Blood Pressure Normal Comments and History of severe/chronic injury/illness Head Concussion History Gross Neurological Function and Balance Testing EENT Neck Chest Abdominal Back Shoulder/Upper Arm Elbow Forearm/Wrist/Hand Hip/Thigh Knee Low Leg/Ankle/Foot NO RESTRICTION for intercollegiate athletic participation OR RESTRICTED participation to MD, DO, NP, PA signature DATE Printed MD, DO, NP, PA Name and Address

4 Form B: Pre-Season Health History Questionnaire Print Clearly Name: Local Address: (include city an zip code if not in La Crosse) Sport(s): Cell Phone: Date of Birth: / / Sex: M F Other Year in School: School I.D # (or SS#): Season of Eligibility: Record Illnesses-check those which have occurred at any time/start those suffered in last 5 years. Asthma Hernia Pneumonia Epilepsy Diabetes Appendicitis Tuberculosis Measles Mumps Mononucleosis Chickenpox Rheumatic Fever Indicate which of the following apply to you (EXPLAIN ANY YES ANSWERS BELOW): Yes or No answers MUST be circled for each item Y N Aching Eyes Y N Frequent Urination Y N Blurred Vision Y N Painful Urination Y N Hearing Loss Y N Kidney Stone or Blood in Urine Y N Recurring Headaches Y N Missing Kidney or other Paired Organs Y N Blackouts Y N Abdominal Pains Y N Fainting Spells Y N Stomach, Liver, Intestinal Problems Y N Painful Joints Y N Loss of Memory or Amnesia Y N Bone, Joint or Other Deformity Y N Loss of a Finger or Toe Y N High or Low Blood Pressure Y N Feet Problems Y N Shortness of Breath Y N Back Problems Y N Pain or Pressure in the Chest Y N Heart Problems Y N Frequent Nose Bleeds Y N Motion Sickness Y N Frequent Sore Throat Y N Recent Weight Loss or Weight Gain Y N Seizures Y N Frequent Trouble Sleeping Y N Heat Illness Explanation of Y Answers:

5 Form B: Health History Questionnaire Current Weight: Highest Weight: Lowest Weight: (over past year) (over past year) Record serious injuries and/or surgeries in the last year be specific and give dates. If none put N/A Eyes, Ears, Nose, and Throat: Head: Neck & Spine: Chest: Abdomen: Upper Extremity: Lower Extremity: List any and all medications and/or supplements you are presently taking and why: (If none, write NONE) Do you wear corrective lenses? Contacts: Y N Glasses Y N Y N Has a physician ever denied, or restricted, your participation in sports for any reason? If yes, please EXPLAIN: Parents Name: Parents Address: Parents Phone ( ) I have completely disclosed all pertinent information to the best of my knowledge. I also accept the responsibility for reporting all of my injuries and illnesses to the UW-L athletic training staff, including signs and symptoms of concussions. Student-Athlete s Signature:

6 Form C: Insurance Information Student Athlete Name: Date of Birth: School ID #: Sport(s): Academic Year: The Acknowledgement of Insurance Requirements must be read, understood, and signed as well as this form completed PRIOR to the student-athlete participating in practice and/or competition. It is the responsibility of the student-athlete/family to communicate any change in policy/coverage that may take place during the year. Parent/Guardian Name: Address: Home Phone: Work Phone: Policy Holder Name: Policy Holder Date of Birth: Home Phone: Relationship to Student-Athlete: Work Phone: Insurance Company Name: Insurance Company Address: Group #: I.D. #/Policy #: Effective Date of Policy: Expiration Policy Limit: Enrolled in HSA/HRA: YES NO (circle one) Policy Deductible: Policy Co-Pay: Does this policy cover athletically-related injuries? Yes or No (circle one) I have read and agree to comply with the provisions of the Acknowledgement of Insurance Requirements. Parent/Guardian Signature and Date Student-Athlete Signature and Date

7 Form D: Acknowledgement Of Insurance Requirements YOU MUST INCLUDE A COPY (FRONT AND BACK) OF YOUR CURRENT INSURANCE CARD WITH THIS COMPLETED INSURANCE INFORMATION FORM (PARENT VERSION- if student is covered under parental insurance) I,, as parent, guardian or legal representative, attest that (name, please print) participating in has insurance (student-athlete name, please print) (sport(s)) coverage under a current, in-force insurance policy for injuries that occur while he/she is participating in intercollegiate athletics. This coverage has limits of at least $90,000. If there is a material change in coverage or expiration of coverage, I agree to immediately notify UW-L of this development and update the insurance information I have on file with the athletic trainers at the University of Wisconsin La Crosse. I understand and agree that UW-L will assume no responsibility whatsoever for the payment of, or authorization to pay, medical expenses resulting in injuries that occur while participating in intercollegiate athletics at the University of Wisconsin La Crosse. (signature) (date) (STUDENT VERSION- if student has independent insurance, not under parental insurance) I,, participating in attest that I have insurance coverage (student-athlete name, print) [sport(s)] under a current, in-force insurance policy for injuries that occur during my participation in intercollegiate athletics. This coverage has limits of at least $90,000. If there is a material change in coverage or expiration of coverage, I agree to immediately notify UW-L of this development and update the insurance information I have on file with the athletic trainers at the University of Wisconsin La Crosse. I understand and agree that UW-L will assume no responsibility whatsoever for the payment of, or authorization to pay, medical expenses resulting in injuries that occur while participating in intercollegiate athletics at the University of Wisconsin La Crosse. (signature) (date)

8 Student-Athlete Preventative Cardiac Testing for Participation in UW-La Crosse Athletics Sudden cardiac death (SCD) is sudden, unexpected death caused by loss of heart function. In a younger population SCD is often due to congenital heart defects. Although SCD in athletes is rare it can and does occur. Most SCD occurs while playing team sports; in about one in 100,000 to one in 300,000 athletes and more often in males. We strongly believe that if we can prevent that one case our efforts through the testing described below is worthwhile. The American Heart Association recommends cardiovascular screening for high school and collegiate athletes. UW-La Crosse Athletic Training has partnered with Wimbledon Health Partners (WHP) in order to be able to provide the following testing to our incoming student-athletes: These tests include: -EKG (electrocardiogram) -Echo -Select Vascular Exam Through this testing it is our goal to confirm there are no cardiac or vascular abnormalities that may predispose the participating student-athlete to sudden cardiac death during their athletic career at UWL. This testing will occur free of cost to both the student-athlete and their parents/guardians. By the student-athlete meeting the criteria of genuine financial hardship, making less than $23,500/annually, and signing a financial hardship waiver this will result in no billing being sent to the student or their family. If there are concerns around this process please contact AT Services. Following is a general description of how the process works to provide the testing. Pre-Testing -Student athlete signs up for testing appointment to be conducted campus with WHP technicians. -Basic insurance information from Form C along with a copy of the insurance card is submitted to WHP for processing. Testing -Student-athlete attends appointment for cardiac testing that lasts ~75-90 minutes. -During check-in the student-athlete signs a financial hardship waiver indicating if they make less than $23, year. -Testing data is immediately sent to a board certified cardiologist for review within 21 business days unless potential abnormality is noted, in which case, studies are read in a stat fashion and reviewed within 24 hours. After Testing -WHP bills out for the tests that were done and will accept whatever your insurance deems appropriate for coverage. This could potentially be all of the testing is covered, a portion of the testing is covered or no testing is covered at all. The policy-holder will then receive an explanation of benefits (E.O.B) stating what the insurance covered. On this paper will also be an amount you will owe the provider. A bill for this amount will not show up to you as we have each student-athlete complete the financial hardship waiver. This releases WHP from being responsible to bill for this amount and again why a bill for the amount noted on the EOB will never be generated. -If by chance a Health Savings Account (HSA) or other account is deducted from please contact Joel Luedke, , immediately to get the issue resolved. Our implementation of this program is focused solely on the health and safety of the student-athletes and not to create any financial stress or burden to the student-athlete or their family. My signature below acknowledges that I have been given information in regards to the cardiac testing. NAME (PRINT) SIGNATURE DATE: Parent/Guardian Signature (required) DATE:

9 Form E: Student Athlete Authorization/Consent For Disclosure of Protected Health & Medical Information I hereby authorize all members of the University of Wisconsin-La Crosse Athletic Training Staff, Team Physicians, or any other physicians or health care professionals to disclose and 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 the following: -Athletic Training Staff -Coaching Staff/Members of the Athletic Department -Parents/Guardians -Student Athletic Trainers -Team Physicians -Student Health Center -Professional Teams -Gundersen Health System/Mayo Health Systems/Other Medical Health Facilities -Teammates The information includes injuries or illnesses relevant to past, present, or future participation in athletics at the University of Wisconsin-La Crosse. I understand that my injury/illness is protected by federal regulations under either the Health Information Portability and Accountability Act (HIPAA) or the Family Educational Rights and Privacy Act of 1974 (the Buckley Amendment) and may not be disclosed without either my authorization under HIPAA or my consent under the Buckley Amendment. I understand that my signing of this authorization/consent is voluntary and that my institution will not condition any health care treatment or payment, enrollment in a health plan or receipt of any benefits (if applicable) on whether I provide the consent or authorization requested for this disclosure. The reason for this disclosure is to advise any of the above individuals 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 not all of the entities receiving the information are health care providers or health plans covered by federal privacy regulations, and that the information described above may be re-disclosed publicly. I understand that the University of Wisconsin-La Crosse will not receive compensation for its use/disclosure of the information. I also understand that entities listed above are not covered by the Buckley Amendment or HIPAA and that these regulations will not apply to the entities use or disclosure of my injury/illness information. I may inspect or copy any information used/disclosed under this authorization. I understand that I may revoke this authorization at any time by notifying in writing, the Director of Athletic Training Services, 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/consent expires 380 days from the date it is signed. A photocopy of this authorization shall be considered as valid as the original. Name: School ID #: Signature: Date of Birth: Sport: SIGNATURE OF PARENT/LEGAL GUARDIAN (if student-athlete is under 18 years of age) DATE

10 Form F: Student-Athlete Authorization/Consent for Disclosure of Protected Health Information for NCAA-Related Research Purposes I, hereby authorize Name of Student-Athlete Name of my Institution and it s physicians, athletic trainers and health care personnel to disclose my protected health information including, without limitation, any information regarding any injury, illness, treatment or participation related to or affecting my training for and participation in intercollegiate athletics to the National Collegiate Athletic Association (NCAA), and its designated employees, agents and/or contractors. I further authorize the NCAA to disclose, and/or use, such information as provided herein. I understand that my participation and protected health information may be disclosed to, and/or used by, the NCAA, and authorized third parties to receive such information for the purpose of using injury, relevant illness and participation information collected form multiple student-athletes and institutions in a manner that does not identify my school or myself. The information is provided to NCAA committees, athletics conferences and individual schools, and NCAA-approved researchers to evaluate the effectiveness of health and safety rules and policy, and to study other sports medicine questions. Selected de-identified summary (aggregate) data also are made accessible to the general public as a service to further the general understanding of athletic injury patterns and help develop education on studentathlete health topics. I am making this authorization/consent voluntarily to release my health information otherwise protected by federal regulations under either the Health Information Portability and Accountability Act (HIPAA) or the Family Education Rights and Privacy Act of 1974 (the Buckley Amendment). The NCAA and institution are not requiring this authorization/consent to be signed. I understand that while HIPAA regulations may not apply to NCAA use or disclosure of my injury/illness information, the NCAA is committed to protecting my privacy. I understand that my data will be stored securely within industry standards. This authorization/consent for transfer of protected health information expires 545 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 director of athletics of my institution. I understand that a revocation takes effect on its request date and does not affect any action taken prior to that date. Printed Name of Student-Athlete Signature Date

11 Form G: Sickle Cell Trait Acknowledgement Form What is sickle cell trait? Sickle cell trait is a relatively benign condition, but is considered to be a risk factor for sudden death in relatively healthy athletes or physically active individuals associated with extreme exertion. Sickle cell trait is not a disease like sickle cell anemia. It is the inheritance of one gene for normal hemoglobin (A) and one gene for sickle hemoglobin (S), giving the genotype AS. Sickle cell trait (AS) is not sickle cell anemia in which the genotype is (SS) and two abnormal genes are inherited. Sickle cell anemia causes major anemia and many clinical problems for people that have the genotype SS. In both genotypes, however, the resultant abnormal hemoglobin (sickle hemoglobin) deforms the red blood cells when they are under low oxygen conditions. Unlike normal red blood cells, which are usually smooth and deformable, the sickle red blood cell cannot squeeze through small blood vessels. The sickle cells block little vessels depriving the organs of blood and oxygen. This leads to the periodic episodes of pain and can damage the vital organs. What makes an individual more prone to symptoms of the disease if they have the sickle cell trait? Exposure to prolonged hypoxic conditions such as at high altitude can cause sickling of the red blood cells in the kidney and spleen, resulting in complications. Another suggestion states that a grave hazard for some people with sickle cell trait can occur when they charge into maximal exercise to which they are unaccustomed. Severe exertion can lead to rhabdomyolysis and acute renal failure. Other cases state that dehydration can be a precipitating factor in the development of sickling in muscle capillaries. What populations are at high risk of having sickle cell trait? People at high risk are those whose ancestors come from Africa, South America, Central America, Caribbean, Mediterranean countries, India and Saudi Arabia. Sickle cell trait occurs in about 8% of the United States African-American population and rarely in the Caucasian population. Do athletes at UW-La Crosse need to know if they have the sickle cell trait, in order to compete in Intercollegiate Athletics? Following the recommendations by the National Athletic Trainers Association (NATA) and the College of American Pathologists (CAP), if you do not know if you have the trait, it is highly recommended that you be tested to determine if you are a carrier of the sickle cell trait. It will be up to each individual athlete to decide if they want to be tested if they do not know their sickle cell status. Those who do not know their status can waive their right to be tested. Those who wish to be tested should contact their Certified Athletic Trainer so they can assist you in getting tested. How will an athlete be tested at UW-La Crosse? Screening can be accomplished with a simple blood test at the Student Health Center on campus and it is relatively inexpensive. Each individual tested will be personally responsible for paying for the test. What precautions do I need to follow if I am positive for sickle cell trait? If you have the sickle cell trait, please indicate that below. Your team s Certified Athletic Trainer will contact you to give and go over the precautions needed for a student-athlete with the sickle cell trait. STUDENT ATHLETE TO COMPLETE THE FOLLOWING: 1. Have you been tested for the sickle cell trait? Yes No Don t Know If YES answer next question, if NO proceed to third question. 2. What was the result of the sickle cell trait test? Negative Positive Don t Know 3. Do you wish to waive the right to know your SCT results? YES NO 4. Do you wish to be tested if you don t know? YES NO My signature below acknowledges that I have been given information in regards to the sickle cell trait. I have indicated that I have been tested and know my results from the past, or don t know and either waive my right to be tested or wish to be tested. I also understand that any costs associated with testing will be my responsibility. NAME (PRINT) SIGNATURE DATE SPORT Parent/Guardian Signature (if SA is under 18)

12 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 or being hit by a piece of equipment such as a bat or ball. -Can change the way your brain normally works -Can range form 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 athletic departments policy for safety and the rules of the sport. -Practice good sportsmanship at all times. -Practice and perfect the skills of the sport. University of Wisconsin La Crosse Form H: NCAA Compliance Statement Concerning Concussion Injury 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. For more information and resources, visit and I affirm that I have read and fully understand the aforementioned facts about concussions. As a student-athlete at the University of Wisconsin-La Crosse, I agree to immediately report all injuries and/or illnesses to the Athletic Training Staff and Head Coach, including any signs and/or symptoms of concussions. Student-Athlete Printed Name Student-Athlete Signature If Student-Athlete is under 18 years of age, Parent/Guardian must also sign: Parent/Guardian Printed Name Parent/Guardian Signature

13 Form I: Student-Athlete Consent for Medical Treatment & Catastrophic Injury Assumption of Risk Student-Athlete Consent for Medical Treatment I authorize the UWL Athletic Training staff, UWL counseling and nursing staff, team or consulting physicians and athletic training staff, team or consulting physicians and other medical personnel at host schools to perform or initiate medical treatment as may be necessary for my health and welfare. This consent is effective with respect to injuries occurring during practices for and participation in various athletic contests and events, as well as injuries occurring during transportation to or from such practice or contest sessions. This authorization includes preventative treatment, immediate first aid and emergency treatment, x-rays, physical exams, emergency surgery, physical therapy, hospitalization, follow-up care, and rehabilitation in the UWL athletic training center, UWL Student Health Center and local hospitals. I consent for the UWL Athletic Training staff or team of referring physicians to prohibit me from further participation in athletic practices or contests because of injury or an undue risk of harm, provided this does not constitute any waiver of my rights under Section 504 of the Rehabilitation Act. Student-Athlete Printed Name Student-Athlete Signature If Student-Athlete is under 18 years of age, Parent/Guardian must also sign: Parent/Guardian Printed Name Parent/Guardian Signature Catastrophic Injury Assumption of Risk The possibility of sustaining a catastrophic injury, which could lead to permanent disability or even death, is inherent in any athletic activity. I understand that the potential of a catastrophic injury does exist, even though the likelihood of such an injury is limited. With this information, I understand the importance of rules and procedures as well as the necessity of using proper techniques. Furthermore, I understand that the possibility of a catastrophic injury does exist even though proper rules and techniques of my sport are followed to the fullest. I hereby release and hold harmless UWL and all of its holdings and employee s from all liability for any and all damages from injuries and or death that may occur while I am participating in UWL sports programs. Student-Athlete Printed Name Student-Athlete Signature If Student-Athlete is under 18 years of age, Parent/Guardian must also sign: Parent/Guardian Printed Name Parent/Guardian Signature