Try out Procedure. Dear Potential Student-athlete: Please complete the attached forms and return to the Sports Medicine Staff.

Transcription

1 Try out Procedure Dear Potential Student-athlete: Please complete the attached forms and return to the Sports Medicine Staff. (Check box when completed) PLEASE NOTE 1. Completed Northeastern University Medical History & Pre-Participation Physical Examination Form and waivers. 2. Completed and signed Walk-On Medical Waiver Form. 3. A currently signed (within one calendar year) physical report stating that you are healthy to participate in intercollegiate athletics without limitation. The Northeastern University s Health and Counseling Services physical report may be used for this purpose. If utilizing the Northeastern University s Student Health Service physical report and immunization form, a copy must be obtained from University Health and Counseling Service. Each walk-on is responsible for obtaining this copy. (Please note, turnaround time is 1-4 business days) All coaches are to begin the walk-on procedure with the Northeastern University Director for Compliance. In order for the Official Addition Roster Change Form to be signed by a member of the Sports Medicine staff, and the walk-on individual receive medical clearance from the Northeastern University Sports Medicine Department, ALL of the following forms must be on file with the Northeastern University Sports Medicine Department: o A completed Sports Medicine Medical History Form, reviewed by a member of the Northeastern University Sports Medicine Staff o A signed waiver form o A copy of a physical (within one calendar year) a physician s signature on file The walk-on athlete will be allowed to compete for no more than Seven Calendar Days (Rowing 14) once all their information is on file. If after the Seven Days (Rowing 14), and the walk-on is expected to continue participation with the team, he/she must be screened by a Northeastern University Sports Medicine Team Physician. The walk-on will not be allowed to participate with their team after the Seven Day Try Out and prior to their screening from a Northeastern University Sports Medicine Team Physician. Sincerely, Northeastern University Sports Medicine Staff

2 Health Insurance Information for Academic Year I have read and understand the attached medical insurance procedure for student-athletes. This form must be signed and returned prior to clearance for athletic participation for your son/daughter. Please note: in typing your name, this serves as an "electronic signature" which is understood to be the legal equivalent in all ways to a hand written signature. Parent/Guardian Signature: DATE / / Last Name First Name MI M F Athlete s Home Address Home Phone Number Cell phone Athlete s DOB / / NU # Sport(s) Complete Name of Primary Insurance Company Insurance Address Policy Holder: Last Name First Name MI Policy Holder s Address Policy Holder s DOB / / Does your insurance plan have a deductible? Yes No If yes, how much? Does your insurance plan require a co-pay plan for services and/or prescriptions? Yes Does this insurance company require pre-certification for the following services? Xray MRI Hospital Admission Consultation outside of Network Other; If so, please list: Please copy the front and back of your primary insurance card and affix it below. Front Back No

3 ONLY COMPLETE THIS PAGE IF YOU WISH TO UTILIZE OR HAVE A SECONDARY INSURANCE POLICY Complete Name of Primary Insurance Company Insurance Address Policy Holder: Last Name First Name MI Policy Holder s Address Policy Holder s DOB / / Does your insurance plan have a deductible? Yes No If yes, how much? Does your insurance plan require a co-pay plan for services and/or prescriptions? Yes Does this insurance company require pre-certification for the following services? Xray MRI Hospital Admission Consultation outside of Network Other; If so, please list: Please copy the front and back of your primary insurance card and affix it below. Front Back No

4 NORTHEASTERN UNIVERSITY MEDICAL HISTORY & PRE-PARTICIPATION Date / / Last Name First Name MI Sport(s) M F Age Race (optional) DOB / / NU # Athletic Classification: Fr So. Middler Jr. Sr. Permanent Address: Local Dormitory or Apartment Address: Cell Phone #: Home Phone #: I. Father s /Guardian s Name: Address Home Phone Business Phone Cell Phone II. Mother s/guardian s Name: Address Home Phone Business Phone Cell Phone III. In case of an emergency when parent/guardian cannot be reached contact: Relationship Address Home Phone Business Phone Cell Phone IV. Name of Family Physician(s): Address Business Phone V. High School Attended: Phone Number: Address Coaches name: Athletic Trainers Name:

5 1. Are you Epileptic or ever have had an Epileptic seizure? If yes, list all medications you take for this condition: YES NO 2. Do you have a Heart Disease? If yes, list any medications taken for the condition. YES NO 3. Do you have any allergies? What and what is the typical reaction? What medication do you take for this allergy? 4. Do you carry an Epipen with you for your allergies? YES NO 5. Do you now have Sickle Cell Anemia? YES NO 6. During the twelve months have you had any type of problem with tolerance to exercise? If yes, please describe. YES NO 7. Have you ever passed out or had syncope? 8. Has any blood relative ever had clinically important arrhythmias? YES NO 9. Has any blood relative ever had heart trouble under the age of 40? YES NO 10. Has any blood relative ever had Hypertrophic cardiomyopathy? YES NO 11. Has any blood relative ever had Marfan's Syndrome? YES NO 12. Have you ever been diagnosed with any clinically important arrhythmias? YES NO 13. Have you ever been diagnosed with dilated cardiomyopathy? YES NO 14. Have you ever been diagnosed with Hypertrophic cardiomyophathy? YES NO 15. Have you ever been diagnosed with Long QT syndrome? YES NO 16. Have you ever been diagnosed with Marfan syndrome? YES NO 17. Have you ever had a Concussion? If yes, list the number of times and severity of each. YES NO 18. Have you ever had or do you now have pain/pressure in chest, and if so at what age? YES NO 19. Have you ever had or do you now have shortness of breath, and if so at what age? YES NO 20. Have you ever sustained a neck or cervical injury? If so, were you hospitalized, and how severe was the injury? YES NO 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 we may be able to better serve you with our best medical care. YES YES NO NO

6 All statements and answers in the above medical history questionnaire are true and completely represent my current health status to the best of my knowledge. I have no abnormality, limitation, or restriction not mentioned in this record. I understand that this information is to help determine my fitness to participate in athletics, and to aid in the treatment and diagnosis of future injuries/illnesses that I may incur. Please note: in typing your name, this serves as an "electronic signature" which is understood to be the legal equivalent in all ways to a hand written signature DATE / / PRINTED NAME OF ATHLETE (First) (Middle) (Last) DATE / / SIGNATURE OF ATHLETE DATE / / SIGNATURE OF PARENT/GUARDIAN (IF STUDENT IS A MINOR)

7 Try-out Medical Waiver Form I am aware that participating in any sport can be a dangerous activity involving many RISKS OF INJURY. I understand that the dangers and risks of participating in sports include, but are not limited to death, serious neck and spinal injuries which may result in complete or partial paralysis, brain damage, serious injury to virtually all internal organs, serious injury to virtually all bones, joints, ligaments, muscles, tendons, and other aspects of my body, general health, and well being. I understand that the dangers and risks of participating in sport may result not only in serious injury, but in a serious impairment of my future abilities to earn a living, engage in other business, social and recreational activities, and generally enjoy life. ends: Please note: in typing your name, this serves as an "electronic signature" which is understood to be the legal equivalent in all ways to a hand written signature Athlete Name: Athlete Signature: DATE / / As the parent/guardian of the above-named athlete, I agree to the above statement: NU ID: Sport (s): Parent/Guardian Signature: DATE / / (if Athlete is a minor) Section to be completed by Sports Medicine Staff ONLY: Try-out approved by: Date: (Name of Staff Member) Date try-out period begins: Date try-out period

8 Sickle Cell Trait Information Sheet and Waiver In April of 2010, the NCAA Division I Legislative Council decided that all Division I student athletes must be tested for the sickle cell trait, provide proof of a prior test, or sign a waiver, releasing an institution from liability if a Student-athlete opts not to be tested or provide proof of an earlier status test. This new rule is effective beginning with the academic year. Northeastern University is supportive of this decision and requests that student-athletes provide Sports Medicine with appropriate documentation of their sickle cell trait status. If student-athletes do not know their status, it is recommended they undergo testing to determine whether they are positive for the sickle cell trait. If a student chooses not to provide the requested information to Sports Medicine or not to be tested, he/she must sign the waiver/release below. In order to assist you in making an informed decision regarding this issue, general information about sickle cell trait follows below. Sickle Cell Sickle Cell is a genetic disorder of the blood that causes the body to produce hard, sickle-shaped red blood cells that can block blood vessels and starve the body of oxygen. There are approximately over 72, 000 Americans with sickle cell disease and over 2 million Americans who carry the sickle cell trait. While sickle cell trait is most predominant in African-Americans and those of Mediterranean, Middle Eastern, Indian, Caribbean, and South and Central American Ancestry, persons of all ancestries and races may test positive for sickle cell trait. Sickle cell trait is generally benign, but during intense, sustained exercise lack of oxygen in the muscles may cause the sickling of red blood cells (red blood cells change from the typical disc shape into a sickle or crescent shape). The sickle-shaped cells can accumulate in the bloodstream, blocking blood vessels. This can lead to collapse and/or even death due to a rapid breakdown of muscles starved of blood. Other problems associated with sickle cell trait may include increased urinary tract infections in women, blood in urine, and exertional heat and/or altitude illnesses. More information about sickle cell trait and the NCAA s decision may be found at Testing for Sickle Cell Trait Northeastern and the NCAA recommend that all student-athletes know their sickle cell trait status. Testing can be conducted at University Health and Counseling Services or through a physician or laboratory facility of your own choosing. If you choose to undergo testing, all associated costs are your own responsibility. Appropriate documentation of sickle cell trait status must be provided prior to any athletic participation. If you choose not to be tested or not to provide appropriate documentation of your sickle cell trait status, you must complete the waiver/release below. The waiver/release must be completed prior to any athletic participation. I,, understand and acknowledge that the NCAA and Northeastern University recommend that all student-athletes have knowledge of their sickle cell trait status. In addition, I have read, acknowledge and understand all of the above provided information about sickle cell trait and testing and the NCAA and Northeastern recommendations. By signing this waiver and release, I confirm that I do not wish to undergo sickle cell trait testing and/or to provide appropriate medical documentation of my sickle cell trait status to Northeastern University. By signing this waiver/release, I voluntarily and forever release, discharge, hold harmless and indemnify Northeastern University, its trustees, officers, faculty, employees, students, and agents from any and all costs, liabilities, claims, expenses, demands, or causes of action on account of any loss or injury or death that may result or in any way be caused, related or connected to my decision not to follow the recommendations of the NCAA and Northeastern University and/or my decision not to undergo testing to determine my sickle cell trait status and/or to provide my status information to Northeastern University. By signing below, I acknowledge that I have read and understand this document with full knowledge and comprehension of its significance: Printed name of Student-Athlete: Signature of Student Athlete: Signature of Parent/Guardian if Student Athlete is under 18 Years of Age Date: Date:

9 Pre-Participation Exam The undersigned here within, A. Understands that I must refrain from practice or play while ill or injured whether or not receiving treatment until I am discharged from treatment or given permission by the health care provider to restart participation despite continuing treatment. B. Understands that passing the physical examination does not necessarily mean that I am physically qualified to engage in athletics, but only that the examiner did not find a medical reason to disqualify me at the time of said exam. C. Acknowledges that ALL questions on this form have been answered completely and truthfully to the best of my knowledge. Printed Name of Student-Athlete: Signature of Student- Athlete: As the parent/guardian of the above-named athlete, I agree to the Team Physician Clearance statement: Date: Parent/Guardian signature (if Student-Athlete is a minor): Date: Assumption of Risk Injury is an inherent aspect of sport. I understand that through my participation in the intercollegiate athletic program at Northeastern University I am subject to the possibility of injury, and also understand that by my participation, I accept the risk of possible injury. I understand that those who are responsible for the conduct of my sport have taken reasonable precautions to minimize such risks. This statement will remain in effect until such time as it is revoked in writing. By signing below, I acknowledge that I have read and understand the above statement Signature of Student-athlete Parent/Guardian Signature if Student-Athlete is under 18 Date Printed Name of Student-Athlete Date MM/DD/YYYY

10 AUTHORIZATION FOR RELEASE OF MEDICAL/PERSONAL INFORMATION: I,, authorize Northeastern University and its employees and representatives to release pertinent (Printed name of student-athlete name) personal and insurance information to any interested medical care provider and the coach of my sport. This information may need to be provided to interested persons in the event that I require medical care. This information may include, but is not limited to: my name, date of birth, social security number, insurance information, parent s telephone numbers, school and home addresses and emergency contacts. I also authorize Northeastern University and any physician, certified athletic trainer or other health care provider retained by Northeastern University to release and discuss with the coach of my athletic team, the Northeastern University athletic administration or any interested health care provider, information concerning my past and present general health, provided that Northeastern University or any such health care provider has determined in its, his or her sole discretion that such information may be relevant to my ability to participate, or continue to participate, in any Northeastern University athletic program. For good and valuable consideration, the receipt of which is hereby acknowledged, I release Northeastern University (including its offices, trustees, employees, agents and representatives) from any and all claims and liability arising from the release by Northeastern University or my medical records or other personal information in accordance with the terms of the foregoing authorization. By signing below, I acknowledge that I have read and understand this statement. Student-Athlete Signature: Date: I,, the parent/guardian (if student is a minor) of the above-named student-athlete agree to the Authorization for release of medical/personal information for my son/daughter. Parent/guardian signature (if Student-Athlete is a minor): Date: Required Immunization Documentation All incoming Northeastern University STUDENTS are required to have up-to-date immunization records on file with the University Health and Counseling Services (UHCS) office. A student will have a Health Center hold if the student has failed to provide complete documentation of immunizations in accordance with Massachusetts state law. Deadline for providing this information are as follows: *The end of June for undergraduate students entering in the following Fall; *The beginning of December for undergraduate students entering in the following Spring; *One month prior to the beginning of a Graduate student or Law student s program. Health Center holds will prevent a student from registering themselves for an upcoming semester. The Health Center hold also will prevent a student's ability to complete "I Am Here. For questions about holds due to state mandated immunity requirements, please cell or UHCS general box at UHCS@neu.edu. This form is separate from the documentation required of STUDENT-ATHLETES and is required by ALL STUDENTS and is to be submitted directly to UHCS. A student at Northeastern University must provide the Health Center with proof of immunity to certain diseases, as specified below. Documentation of immunizations and/or titers must be on the University's Health Report, or a clinician s letterhead or prescription slip, signed by a nurse, nurse practitioner, or physician assistant. Alternatively, documentation may be provided by the student's high school, previous college, or military facility, again with clinician signature. Required Immunizations: 2 MMR, Tetanus/Diphtheria/Pertussis, Hepatitis B, Varicella/Chicken Pox, and Meningitis (or signed waiver) I,, understand and acknowledge the above statement and comprehend its significance. (Printed name of Student-Athlete) By signing below, I acknowledge that I have read and understand the above statement: Signature of Student-Athlete: As the parent/guardian of the above-named athlete, I agree to the Required Immunization Documentation statement: Parent/Guardian signature (if Student-Athlete is a minor): Date: Date:

11 Medication Administration The Northeastern University Sports Medicine Department has Non-Prescription oral medications available for Student athletes as needed per Sports Medicine staff recommendations as supervised directly by Team Physician. These medications can be purchased over the counter at supermarkets and pharmacies. These medications can be requested by student athletes and are administered at the discretion of the sports medicine staff. I,, understand and acknowledge the above statement and comprehend its significance. (Printed name of Student-Athlete) By signing below, I acknowledge that I have read and understand the above statement: Student- Athlete Signature: As the parent/guardian of the above-named athlete, I agree to the Medication Administration statement: Date: Parent/Guardian signature (if Student-Athlete is a minor): Date: Intercollegiate Athletic Participation by the Pregnant Student-Athlete Females Only I understand that if during my athletic career at Northeastern University I become pregnant that I will inform the sports medicine department immediately. I understand that if I do not inform the sports medicine department there is potential to have labor and birth complications, damage or loss of the unborn fetus, and potential health complications to myself. I am fully aware of the potential consequences, and I accept and assume liability if injury were to occur as a result of participating in intercollegiate sports for Northeastern University. Furthermore, I agree to follow all safety precautions and will discontinue participation as recommended by the Northeastern University Sports Medicine staff. I hereby release and indemnify Northeastern University, its trustees, officers, agents, physicians and sports medicine staff, coaches, and employees from all suits, claims, or causes of action related to my potential condition. This statement will remain in effect until revoked in writing. I,, understand and acknowledge the above statement and comprehend its significance. (Printed name of Student-Athlete) By signing below, I acknowledge that I have read and understand the above statement: Student-Athlete signature: Date: As the parent/guardian of the above-named athlete, I agree to the Intercollegiate Athletic Participation by the Pregnant Student Athlete statement: Parent/Guardian signature (if Student-Athlete is a minor): Date:

12 Consent to Treat I hereby authorize the Certified Athletic Trainers and sports medicine staff to evaluate and treat any injury/illness that occurs during my participation in intercollegiate athletics at Northeastern University. I understand and agree that if I experience an injury/illness that it is my responsibility to inform the Sports Medicine Department or Certified Athletic Trainer who is coordinating my care. While under the medical care of Northeastern University s Sports Medicine Department an athlete may not return to participation until they have been medically cleared by either a Northeastern Certified Athletic Trainer or the Team Physician. I,, understand and acknowledge the above statement and comprehend its significance. (Printed name of Student-Athlete) By signing below, I acknowledge that I have read and understand the above statement: Student-Athlete signature: As the parent/guardian of the above-named athlete, I agree to the Consent to Treat statement: Parent/Guardian signature (if Student-Athlete is a minor): Authorization for Release of Medical Information from UHCS Date: Date: I hereby authorize the Northeastern University Sports Medicine Staff to access my medical records at the University Health and Counseling Services in circumstances where the records pertain to and/or affect my intercollegiate athletic participation status. By signing below, I acknowledge that I have read and understand the above statement: Student-Athlete Signature: Date: I,, the parent/guardian (if student is a minor) of the above-named student-athlete agree to the Authorization for release of Medical information from UHCS for my son/daughter. Parent/guardian signature (if Student-Athlete is a minor): Date:

13 TEAM PHYSICIAN CLEARANCE As a current or prospective student-athlete at Northeastern University, I understand and agree to the following statement: (Printed name of Student-Athlete) The Athletic Department of Northeastern University has a designated Team Physician(s). The physician has final approval or disapproval of my participation in intercollegiate athletics at Northeastern University. This includes, but is not limited to the following: pre-participation exam results and illness or injury prior to, during and post season. This decision may be in lieu of or in addition to recommendations by other physicians. By signing below, I acknowledge that I have read and understand this document with full knowledge and comprehension of its significance: Student-Athlete Signature: As the parent/guardian of the above-named athlete, I agree to the Team Physician Clearance statement: Date: Parent/Guardian signature (if Student-Athlete is a minor): Date:

14 NCAA Drug Testing Exception Policy Use of Stimulants to Treat ADD/ADHD Attention Deficit Disorder (ADD) and Attention Deficit Hyperactivity Disorder (ADHD) are common neurobehavioral disorders of childhood that can persist through adolescence and into adulthood. The most common medications used to treat ADD/ADHD are methylphenidate (Ritalin) and amphetamine (Adderall), both are banned under the NCAA class of stimulants. Recently, the NCAA has updated their policy regarding medical exceptions of banned drug classes. The NCAA bans performance enhancing drugs to protect the health and safety of student-athletes, and to ensure a level playing field. The NCAA also recognizes that some of these substances may be legitimately used as medication to treat student-athletes with learning disabilities and other medical conditions. The current policy can be found at: To be considered for medical exception for a medication that contains a banned substance, the student-athlete must provide the required documentation from the prescribing physician: Documentation of the diagnosis and how it was reached through diagnostic testing Documentation of the treatment procedure, name of medication and dosage information and a copy of the current prescription Statement that the student-athlete s medical history exhibits a need for regular use of the drug List of alternative non-banned medications for the treatment of the condition that have been tried/considered Statement that the student-athlete and prescribing physician agree that there is no other appropriate alternative medication treatment available **Starting in August 2009, all student-athletes are required to have this documentation on file with the Northeastern University Sports Medicine staff prior to the start of the athletic year.** Please answer the following question(s), initial, and sign below: Have you been diagnosed as having ADD/ADHD? YES / NO If yes: Are you currently on medication(s) for treatment of ADD/ADHD? If yes, please fill out table below: Medications Dose Prescribing Physician YES / NO I have been informed of the NCAA drug testing exception using stimulants to treat ADD/ADHD. I understand that I am responsible for notifying the Sports Medicine staff and the Athletic Department representative for compliance with regard to my current medical status and need for any NCAA drug testing medical exception. I understand that it is my responsibility to provide the Northeastern University Sports Medicine Department with all required documentation related to the treatment of my condition By signing below, I acknowledge that I have answered truthfully, and have read and understand this document with full knowledge and comprehension of its significance: Student-Athlete Signature Signature of Parent/Guardian if Student-Athlete is Under 18 Years of Age DATE: DATE:

15 NORTHEASTERN UNIVERSITY DEPARTMENT OF ATHLETICS FERPA Authorization for Release of Health Information for Varsity Intercollegiate Athletes Name (Please Print) Sport Date of Birth TO: NU ID Number NORTHEASTERN UNIVERSITY ATHLETIC TRAINERS, PHYSICIANS, STRENGTH COACHES, SPORTS DIETICIANS AND OTHER RELATED PERSONNEL: You are hereby authorized and requested to disclose information and records pertaining to my physical health or condition, whether past, present or future, including all physicals, physicians records, athletic trainers records, diagnoses, treatment information, histories, and prognoses, and including information and records pertaining to any and all injuries or illnesses to (i) Northeastern University Department of Athletics and its personnel (including coaches of my sport) who the University, in good faith, determines have a legitimate need to know and/or (ii) Northeastern University s team physicians; but only disclosing such information to the media as it relates to my ability to participate in my sport. The purpose of this authorization is (i) to assist coaches and other personnel within the Department of Athletics in evaluating my fitness as it pertains to my ability to participate in my sport; (ii) to allow personnel within the Department of Athletics to assist me with respect to my athletic grant-in-aid or with respect to my academic progress; (iii) to assist Northeastern University s team physicians in providing medical care to me; (iv) to meet the requirements of insurers or health plans when such insurers require such information before paying for your health care services; and/or (v) to allow athletic training students and student physicians in training to participate in my medical care or to contribute to their educational training. I hereby agree that the information that is used or disclosed pursuant to this Authorization may be redisclosed by the receiving entity. For example, information given to the media about my physical ability to play my sport will, in all likelihood, be redisclosed to their audience. By signing below, I specifically authorize and consent to all such redisclosures. I understand that the information referenced above is protected by law and may not be disclosed without my consent. By signing this form, I certify that I agree to the disclosure of the records referenced above. A copy of this authorization shall be considered as effective and valid as the original. DATE: Student-Athlete Signature Signature of Parent/Guardian if Student-Athlete is Under 18 Years of Age DATE:

16 Northeastern University Athletic Medical Insurance Coverage Despite our best preventative efforts athletic injuries will occur, many of which will require specialty medical services outside of the Sports Medicine department and the University Health and Counseling Service (student health service). It is very important that you fully understand the Northeastern University policy regarding medical insurance coverage for athletic injuries. Northeastern University does not provide primary medical insurance coverage for intercollegiate athletes or any other special activities group. All medical expenses incurred (including deductibles, co-payments, and other charges) for treatment of athletic related injuries are the responsibility of the student-athlete. This includes, but is not limited to; expenses related to MRI s, bone scans, lab tests, x-rays, hospitalization, surgery, emergency room services, emergency transportation, dental, physical therapy, chiropractic care or other alternative treatments, lost corrective lenses, or medications to treat injuries, illnesses or other medical conditions. This policy applies regardless of whether or not the injury was sustained in a formal practice or competition while representing Northeastern University, either on our campus or while visiting another institution. Northeastern University Athletics will, however, provide insurance for all of our student-athletes that will cover those expenses (other than deductibles) not covered by your primary insurance for any injury incurred during athletic practice or competition. All Northeastern University students are required to provide proof of medical insurance upon entrance to Northeastern. Full-time students at Northeastern University must either enroll in the Northeastern University Student Health Plan or have an approved waiver for coverage under an existing family medical insurance policy. In compliance with Massachusetts State Law all full-time and part-time students meeting 9 quarter/semester credit hours or more will automatically be enrolled in the Northeastern University Student Health Plan. If you have comparable insurance coverage you may waive the Northeastern University Student Health Plan on line at If you do not take the appropriate steps to waive the Northeastern University Student Health Plan, you will automatically be enrolled and therefore you will incur the cost of this plan. Be aware that when purchasing the Northeastern University Student Health Plan, deductibles and co-payments are still in effect. Northeastern Athletic and Sports Medicine Departments strongly urge all student-athletes and their families to closely examine the access to care and benefits associated with an on-campus healthcare plan compared to personal insurance plans, especially for out-of-state athletes. For more information regarding the Northeastern University Student Health Plan, please call The Blue Cross Blue Shield of MA Group directly at or call University Health and Counseling Services at As always, if you have any questions, please ask a the Risk Services office or a member of the Sports Medicine staff. Please be advised that this information is our best current understanding of the process, and may change without notice I have read and understand the above insurance procedure for student-athletes. This form must be initialed and returned prior to clearance for athletic participation for your son/daughter. Student-Athlete Signature: DATE Parent/Guardian Signature (if Student-Athlete is a minor): DATE