To All New Incoming Athletes and Their Parents:

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1 To All New Incoming Athletes and Their Parents: Welcome to Rutgers University Camden! We are looking forward to you joining us on campus and competing in intercollegiate athletics. Prior to your arrival, we ask that you complete the following checklist of items. Please fill out all forms in ink and they must be legible! Please make sure that you read the entire document in which you are signing. If you have had a surgery, illness, or injury in the last year or an ongoing medical issue (ie: heart murmur, sickle cell trait, concussion) that requires another doctor s clearance for participation, you must bring in ALL paperwork in regards to the injury in addition to the clearance. Without that paperwork your physical is considered incomplete and you will be unable to participate. If you are a minor (under the age of 18), please make sure that you go over the forms with your parents and all forms are signed where applicable. Please return all forms, completed and signed to the athletic training staff by AUGUST 1 st, 2013 to the address below or put in our mailboxes located on the lower level of the athletic and fitness center. Athletic Training Staff Athletics and Fitness Center 301 Linden Street Camden, NJ The following items are required in order to begin practicing with your team. o Fill out the following form online with your demographic information and medical history information. You will need your NetID and password to access the form. Please fill out all areas, or they will reset. If a field does not apply, please put N/A. The form can be found at: o Schedule a physical exam at Health Services. Physicals done by your Primary Care Physician will NOT be accepted. Health Services can be contacted at To this appointment, you will need to bring two items: o Complete immunization record. Please do NOT send this to the athletic training staff, as we do not keep this in our files. o Documentation of your sickle cell trait status. This can be obtained from your primary care physician (at time of birth). Per new requirements by the NCAA, it is encouraged that all athletes provide their sickle cell trait status or you will be asked at your exam if you would like to be tested free of charge. More information regarding sickle cell trait can be found at: o An additional orthopedic physical for all athletes will be completed by our team physicians in the athletic training room. The information for this exam will be given to you by your coach and will take place with the rest of your team prior to your season beginning. o Read and sign the Athletic Training Policies and Intercollegiate Athletics and Insurance Disclaimer forms that are attached. o Read and sign the Authorization to Release Health Care Information (HIPAA) form that is attached. (Not required to participate)

2 o Provide a copy of the front and back of your medical insurance cards. If you purchased the school insurance and have not yet received a card, please let us know. o ImPACT Test For SOCCER, BASKETBALL, VOLLEYBALL, BASEBALL, SOFTBALL & LACROSSE Athletes ONLY! - The ImPACT test is done just once and is used in the event of a head injury when you are competing. It is an online neurocognitive test which will test you in areas such as reaction time, memory, and attention span. The test will take you approximately minutes to complete, so please allot an appropriate amount of time to take the test, as you cannot pause it and return to it later. This is a requirement for all incoming athletes regardless of whether you have taken it before at another school. Listed below is the login information for ImPACT which will make you part of the RU-C athletics system. This test must be completed prior to any participation in athletics here at RU-C, including practices. Listed below are a few requirements and reminders for you prior to taking the test: Take the test in a quiet area, free of noises and other distractions. The test is done online, so an internet connection is required. You may take the test on a desktop or laptop, but you MUST have a mouse. A pad mouse will not work. Without a mouse your reaction times may be delayed and can affect the results. Answer the demographic information at the beginning of the test accurately; this is very important, especially in the event you sustain a concussion. This includes prior history of concussion, any medications you may be currently taking, or diagnosed learning disability. Do your best! Do not just click through the test as the test will note your time and you will be flagged and required to take the test again at a time to be determined by the athletic training staff. This test is not about a passing or failing grade, it is to determine what your (not anyone else s) normal or baseline is so we can use that in the event of a concussion. Below is the login information for the ImPACT testing: Go to the following website: The customer code is: 88A8260D98 This will bring you to the start of the test and you can begin. If you have any questions or concerns about any part of this process or paperwork, please feel free to contact the athletic training staff. Again, please complete all paperwork by August 1 st, Thank you for your cooperation and we look forward to seeing you! Heather Hellem, M.Ed., ATC David Seeberger, M.A., ATC Head Athletic Trainer Assistant Athletic Trainer Office: Office: Fax: Fax: heather.hellem@camden.rutgers.edu david.seeberger@camden.rutgers.edu

3 Rutgers University-Camden Athletic Training Policies Rutgers University-Camden employs certified athletic trainers who are qualified to assess, treat, and rehabilitate most injuries you may incur while participating in our intercollegiate athletic program. The certified athletic trainer s qualifications include: certification by the National Athletic Trainer s Association, Licensure with the New Jersey Board of Medical Examiners, certification in CPR, and a minimum of a Bachelor of Science degree in the Sports Medicine field. I understand I have a responsibility to report my injuries and illnesses to the athletic training staff in a timely manner. I also have an obligation to truthfully and fully report my symptoms related to my injuries. Failure to report injuries and proper documentation in a timely manner will nullify any insurance obligations by Rutgers University-Camden. This importance increases when dealing with a head injury or concussion. I understand that failure to report my injuries or not being completely truthful about my symptoms will impact the effectiveness of my care and could result in more serious injury or life threatening results. The NCAA requires that all student-athletes sign a statement where they accept the responsibility for reporting signs and symptoms of a concussion to the Athletic Training staff. I agree to inform the Rutgers University-Camden Athletic Training Staff when I have experienced signs and symptoms of a concussion during the academic year. Concussion symptoms include, but are not limited to: nausea, loss of consciousness, amnesia, dizziness, confusion, headaches, balance problems, double or fuzzy vision, sensitivity to light or noise, feeling sluggish, concentration or memory problems, slowed reaction time or feeling irritable. I understand that the department of athletics is not financially responsible for any expenses incurred by a student-athlete for medical services obtained without referral or authorization by the team physician or a member of the athletic training staff. Further, the department of athletics assumes no financial responsibility for any expenses incurred by a student without medical insurance. All Rutgers University-Camden students are required to have primary medical insurance for enrollment. If there are any changes to the student s primary insurance coverage they must be reported to the athletic training staff, along with front and back copies of the new insurance card within 14 days of the change. Student-athletes are more than welcome to seek a second or third opinion regarding an injury, however, Rutgers University Camden will not be responsible for the charges that you may incur, unless given written permission in advance. Student-athletes who fail to show up for scheduled treatment or rehabilitation may be suspended from athletic activities and with continued non-compliance lose privileges to access of the athletic training room and its services. Student-athletes must understand that he/she must refrain from practice or play while ill or injured, whether or not receiving medical treatment until he/she is discharged from treatment or is given permission by the athletic training staff to restart participation despite continuing treatment. I give permission for Rutgers-Camden s athletic training staff to assess, treat, rehabilitate, and refer me as appropriate during the coming year. Upon completion of my season for the year, I agree to sign and fill out an exit evaluation. This form will be filled out regardless of being cut or dropped from the team for any reason even if under my own choosing, or the physical completion of the sport for the year. This form will be filled out within 48 hours of leaving my team, or within a week of completing my sport. In the event that I do not complete this form, I forfeit my right to secondary insurance coverage for any injury or illness sustained while participating in intercollegiate athletics. My signature below indicates that I have read this entire document, understand it completely, and agree to be bound by its terms. Name: Signature: Parent Signature: (If student athlete is under 18 years of age) Date: Date:

4 Rutgers University-Camden Intercollegiate Athletics and Insurance Disclaimer This certifies that I, (print name) know and understand that participation in intercollegiate athletics involves inherent risks such as, but not limited to: cuts, scrapes, and bruises; muscle strains or ligament sprains; broken bones; illnesses; emergency hospitalization; and in extreme cases, even death. I understand that even when safety precautions are utilized, injuries can occur. I understand that Rutgers University-Camden employs the services of 2 full-time athletic trainers and that if I experience unusual pain or physical discomfort during participation in any sport, I will notify him/her of my symptoms. I have received a full physical examination by Rutgers University-Camden physicians and have been granted clearance to participate in intercollegiate athletics. I understand that having passed the physical examination does not necessarily mean that I am physically qualified to engage in athletics, but only that the physician did not find a medical reason to disqualify me at the time of said examination. I also claim to the best of my knowledge that I do not have any underlying medical/physical disabilities that will preclude my safe participation in this program. I will always wear any required protective equipment while playing and abide by all rules, regulations, and policies applicable to the program. Additionally, Rutgers University-Camden athletics provides a secondary athletic injury policy for every intercollegiate student-athlete at no additional charge. The policy is considered an excess policy, which means it will help cover an unpaid portion of a medical bill after it has been submitted to the athlete s personal primary medical insurance plan. Medical expenses acquired due to an athletic injury will be billed to the primary policy first and if a balance remains, it will be submitted to the secondary insurance plan for consideration of payment. This secondary insurance policy only covers injuries that occur during official, supervised practices or games; pre-existing injuries are not covered. Do not assume all medical expenses will be covered; out of pocket expenses may occur. In full awareness of the above and in full consideration of my participation in intercollegiate athletics, I waive, release, and discharge any and all claims for death, personal injury, or property damage against Rutgers, The State University, its officers, agents, and employees, which I may have, or which I may hereafter accrue me as a result of my participation in intercollegiate activity. I understand that in many cases, athletic injury requires emergency care and medical referrals, which incur medical bills. I agree to indemnify and hold harmless Rutgers, The State University, its officers, agents, and employees from any claim or loss from death, bodily injury, property damage, or medical bill claims arising in any manner out of my presence or activities in the course of my participation in intercollegiate athletics. I agree that I have read and understand the above policy in regard to medical bill processing and payment and accept its terms and conditions. I further understand and agree that this waiver, release indemnity, and assumption of risk is to be binding on my heirs and assigns. Signature: Parent Signature: (If student athlete is under 18 years of age) Date: Date:

5 Rutgers University - Camden Authorization to Release Health Care Information (Please read, as you are not required to sign this form to participate) Name: SS#: Date of Birth: RU ID#: I request and authorize Rutgers University Camden Athletic Training Staff to release pertinent health care information of the patient named above to any necessary physician offices, radiology departments and/or insurance companies on my behalf to expedite treatment and care of any injury or illness I may sustain while competing in intercollegiate athletics at Rutgers University - Camden. I request and authorize any physician offices, radiology departments and/or insurance companies to release health care information about me to the Rutgers University Camden Athletic Training Staff. This includes the following medical providers, but is not limited to: Cooper Bone and Joint Institute, Cooper Radiology, Rothman Institute, South Jersey Radiology, Dr. Lee Cohen s Office and Student Health Services. The information to be released shall include the following: Medical Record (complete); History and Physical; X-Ray, Imaging Reports; Consultation Reports; Laboratory Test Results; Discharge Summaries.. I authorize the Rutgers University Camden Athletic Training Staff to speak with any medical provider I have encountered on my behalf regarding health care services or payment for services rendered due to injury or illness sustained during intercollegiate athletics at Rutgers University Camden. I understand that the purpose for this disclosure is to enable the Rutgers University Camden Athletic Training Staff to coordinate my health care, housing and other specialized needs with appropriate University staff. I authorize my primary insurance company (as completed in my pre-participation paperwork) to release any information to Rutgers University Camden Athletic Training Staff as required in applying for health care services or payment on my behalf. I authorize the Rutgers University Camden Athletic Training Staff to speak with my primary insurance company on my behalf regarding health care services or payment for services rendered due to injury or illness sustained during intercollegiate athletics at Rutgers University Camden. In addition, I authorize Aetna, the University s secondary insurance provider to release any information to Rutgers University Camden Athletic Training Staff as required in applying for health care services or payment on my behalf. I authorize the Rutgers University Camden Athletic Training Staff to speak with Aetna on my behalf regarding health care services or payment for services rendered due to injury or illness sustained during intercollegiate athletics at Rutgers University Camden. I understand that my injury or illness information 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 or withhold 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. I also understand that I am not required to sign this authorization/consent in order to be eligible for participation in Rutgers University Camden Athletics. I understand that while HIPAA regulations do not apply to Rutgers University Camden Athletic Training Department s use or disclosure of my injury or illness information, Rutgers University Camden is committed to protecting my privacy. This authorization/consent expires exactly one calendar year 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 Head Athletic Trainer at Rutgers University Camden. I understand that a revocation takes effect on its request date and does not affect any action taken prior to that date.