Bethune Cookman University Athletic Training Sports Medicine GENERAL ATHLETE INFO (PLEASE PRINT) Student-athlete s Name: Last First MI

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1 Bethune Cookman University Athletic Training Sports Medicine GENERAL ATHLETE INFO (PLEASE PRINT) Student-athlete s Name: Last First MI Sports(s): Grade (circle one): FR SOPH JR SR 5 TH YR Social Security Number : Student ID: Date of birth (DOB): Local Address: Street City State Zip Phone: Cell Mother/Guardian Name: Phone: Dorm SSN or ID# DOB: Local Address: Street City State Zip Phone: Cell Home Work Father/Guardian Name: SSN or ID# DOB: Local Address: Street City State Zip Phone: Cell Home Work Another Emergency Contact Name & Phone: Health Insurance Information Is the athlete currently covered by parents/guardian surgical and/or hospital health insurance policy? YES NO If NO, please refer to Statement Declaring Lack of Health Insurance Form (must be notarized) on next page. If YES, please fill out the information below and provide front and back copies of insurance card on next page: Primary Name on Insurance Policy/Coverer/Policy Holder:) SSN or ID#: Relationship to Athlete: Insured s Employer: _ Insurance Company HMO PPO Other (If HMO, please see HMO request guest membership form) Claims Address: Street City State Zip Phone:( ) Deductible:$ Co-payment: $ Please fill all that apply based from Insurance Card: Contract # Policy # Group# Member # ID# Does your insurance plan include prescription medication coverage? YES NO If yes, Co-payment: $ Primary Care Physician s Name and Phone #:

2 MEDICAL HISTORY (Please return completely filled out prior to physical) Name: Sex: Age: Date of Birth: Grade: Sport(s): Address: Phone (Home) (Cell) Personal Physician & Phone # (if you have one) 1. Have you had a medical illness or injury since your last check up or sports physical? Do you have an on-going or chronic illness? 2. Have you ever been hospitalized overnight? Have you ever had surgery? 3. Are you currently taking any prescription or non-prescription medications or pills or using an inhaler? Have you ever taken any supplements or vitamins to help you gain or lose weight or improve your performance? Y N 6. Have you ever been told you have a heart murmur? 7. Has any family member or relative died of heart problems or of sudden death before age 50? Have you had a severe viral infection (for example: myocarditis or mononucleosis) within the last month? Has a physician ever denied or restricted your participation in sports for any heart problems? 8. Do you have any current skin problems (for example: itching, rashes, acne, warts, fungus, or blisters)? Y N 4. Do you have any allergies (for example: pollen, medicine, food, or stinging insects)? Have you ever had a rash or hives develop during or after exercise? 5. Have you ever passed out during or after exercise? Have you ever been dizzy during or after exercise? Have you ever experienced chest pain during or after exercise? Do you get tired more quickly than your friends do during exercise? Have you ever had racing of your heart or skipped heartbeats? Have you ever had high blood pressure or high cholesterol? 9. Have you ever had a head injury or concussion? Have you ever been knocked out, become unconscious, or lost your memory? Have you ever had a seizure? Do you have frequent or severe headaches? Have you ever had numbness or tingling in your arms, hands, legs, or feet? Have you ever had a stinger, burner, or pinched nerve? 10. Have you ever become ill from exercising in the heat?

3 11. Do you cough, wheeze, or have trouble breathing during or after exercise? Do you have asthma? Do you have seasonal allergies that require medical treatment? Y N 18. Have you ever been tested for sickle-cell trait? What were the results? 12. Do you have problems with your eyes or vision? Do you wear glasses, contacts, or protective eyewear? 13. Do you use any special protective or corrective equipment or devices that aren t usually used for your sport or position (for example: knee brace, special neck roll, foot orthotics, retainer for your teeth, hearing aid)? 14. Have you ever had a sprain, strain, or swelling after an injury? Have you broken or fractured any bones or dislocated any joints? Have you had any other problems with pain or swelling in muscles, tendons, bones, or joints? If yes to any of the above, please check appropriate box and explain. FEMALES ONLY: 19. When was your first menstrual period? When was your most recent menstrual period? How much time do you usually have from the start of one period to the start of another? How many periods have you had in the past 12 months? What was the longest time in between periods in the last year? Head Shoulder Hip Neck Upper Arm Thigh Back Elbow Knee Chest Forearm Shin/Calf Abdomen Wrist Ankle Hand Foot Finger 15. Do you want to weigh more or less than you do now? Do you lose weight regularly to meet weight requirements for your sport? 16. Do you feel stressed out? 17. Record the dates of your most recent immunizations (shots) for: Tetanus Hepatitis B Measles Chickenpox Explain any and all yes answers below: I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Athlete s Signature Date

4 Welcome to intercollegiate athletics at Bethune-Cookman University. We hope that your time here will be the best years of your life. The Bethune Cookman University Sports Medicine Staff is here to help make your athletic endeavors enjoyable and safe. This Pre-participation packet has changed; therefore it is necessary for you to closely examine the following documents so that you may understand the policies and procedures that are required of you as a student-athlete at Bethune Cookman University. Please read and COMPLETE ALL OF THE DOCUMENTS THAT ARE ENCLOSED AND RETURN BACK TO US OR POST-MARKED BY JUNE, 1 ST Use the following checklist to ensure your paperwork is complete: This Form (Welcome Page) General Athlete Info Medical History (front and back) Medical Expense Information Awareness of Insurance Policies Part I & II Awareness of Risk Copy of Insurance Card (front and back) HMO Guest Membership Signature Statement Declaring Lack of Insurance (needs Authorization & Consent for To be notarized and filled out ONLY Disclosure of Protected If you do not have health insurance) Health Information The following must be completed and filed in the athletic training room before you are allowed to participate in any athletic activity (including try-outs). Pre-participation packet and physical Front and back copy of your insurance card (Mandatory). OR a notarized statement declaring lack of health insurance I, (print full name), have read the above and have received the Bethune Cookman University Sports Medicine Pre-participation packet. I understand that I cannot participate in any athletic activity until all of the forms have been returned to the athletic training room. I must either give proof of insurance or provide a notarized written statement that verifies that I do not have any insurance coverage at this time. If at any point I obtain health insurance coverage or my current health insurance changes, I understand that I must disclose this information to the athletic training staff promptly. Additionally, I understand that if I have falsely testified regarding my health insurance status, I will be financially responsible for any medical services provided to me. Bethune Cookman University's athletic insurance policy is described in the sports medicine web-page under Medical Insurance Policy. If you have any questions or concerns regarding any of the following forms, please contact the Bethune Cookman University Athletic Training Room at (386) , or Thank you for your assistance in this matter. We look forward to working with you in the future. Student-athlete signature Date Parent/Guardian signature Date ****ATTN: PARENT/GUARDIAN**** PLEASE MAKE COPIES OF OUR INSURANCE POLICY OR OTHER IMPORTANT INFORMATION FOR YOU TO RETAIN.

5 MEDICAL INSURANCE POLICY The Bethune-Cookman University Athletic Department strongly suggests that scholarship student-athletes have or acquire some form of primary health insurance coverage. Bethune-Cookman University Athletics utilizes a secondary athletic medical insurance policy. The scope of this policy is limited to orthopedic athletic-related injuries. That means it does not cover illnesses or certain health conditions. This is regardless of whether or not the illness or health condition could be considered sports related or occurs during the athlete's school year or during unforeseen weather conditions during games/practices (away or home). ANY INTERCOLLEGIATE STUDENT-ATHLETE WHO SUSTAINS AN ATHLETIC-RELATED INJURY OR ILLNESS WILL FILE WITH THEIR OWN OR PARENT'S/GUARDIAN S PRIVATE HEALTH INSURANCE AS THE "PRIMARY" INSURANCE PROVIDER. THE ATHLETIC ASSOCIATION WILL BE RESPONSIBLE FOR THOSE EXPENSES NOT COVERED BY THE PRIMARY INSURER S POLICY. All health care providers working with Bethune-Cookman University are required to file with the student-athlete's primary insurance prior to submitting any claim to the secondary insurance. FOR THOSE STUDENT-ATHLETES WHO DO NOT HAVE A PRIMARY INSURANCE COVERAGE, THE STUDENT WILL BE HELD RESPONSIBLE FOR ANY PORTION OF THEIR BILLS NOT PAID BY BETHUNE-COOKMAN UNIVERSITY S SECONDARY INSURANCE POLICY. It should be noted that the athletic association may only cover injuries sustained during Bethune- Cookman University Intercollegiate Athletics supervised/authorized practices or games. Additionally, the secondary insurance will only be filed when the student-athlete reports the injury to one of the BCU Athletic Trainers, is evaluated by the athletic trainer, and is referred by the athletic trainer. Any other circumstances under which injuries may occur will be regarded as non-athletic in nature and are not the responsibility of Bethune-Cookman University Athletics, nor is it legal for the athletic department to assume such responsibility. All medical appointments related to athletic participation will be arranged for the student-athletes by the BCU Athletic Training Staff. Appointments made by oneself or by the parents shall be the sole responsibility of the student-athlete and/or the parents/guardians. The Bethune-Cookman University Athletic Department will not be financially responsible for payment of unauthorized appointments. PRIMARY HEALTH INSURANCE: This is either insurance of the athlete (he/she s personal own insurance) or through a parent or guardian's insurance plan. If an insurance claim has been filed with the appropriate insurance company. The athletic trainer will assist in filing the claim, if provided with the necessary information. SECONDARY INSURANCE: This is excessive coverage, meaning it is designed to pay for charges not covered by your personal (primary) insurance program Requirement for coverage by the secondary insurance: If the athlete has notified the athletic training staff of a condition and arrangements are made through the athletic trainer's office for treatment or referral. The school policy will only pay if a physician sees the injury within 30 days from the date of injury as noted on official training room records. If the Athletic Training Staff is presented with an official statement from your insurance company, ("Explanation of Benefits") which indicates that the claim has been turned into your company for processing. ( See Back )

6 If the Insurance Information Form (in this packet) has been completed and returned to the Athletic Training Staff. Any changes in the status of insurance coverage must be made immediately to athletic training staff. Failure to do so, or providing false information about insurance coverage, relinquishes all responsibility for payment by the Athletic Department. The Secondary Insurance Policy WILL NOT cover: DOES NOT COVER DEDUCTIBLES AND CO-PAYMENTS, (for athletes with primary insurance) the athlete/policyholder will be responsible for deductibles and co-payments as dictated by the policy regardless of the injury or condition and how it occurred. The school's insurance policy will not permit payment of these expenses. Please be aware that these payments may be due at the time of the visit and the student-athlete will be responsible for the payment. PRESCRIPTION DRUGS of ANY kind are NO longer covered. Student-athletes must take responsibility for his or her own illnesses PRE-EXISTING injuries or medical conditions MEDICAL ILLNESSES (colds, intestinal virus, flu, tonsillitis, mono, appendicitis, hernias, wart removal, or any other conditions not directly related to an athletic accident.). **Arrangements may be made for treatment of these conditions for the convenience of the athletes; however the athletic department is not responsible for payment. PRE-SEASON PHYSICALS not taken with the team on the pre-set date or at the beginning of the season. DENTAL PROCEDURES-unless the result of an athletic injury and reported that same day. PROCEDURES FOR FILING A CLAIM If an athletic injury occurs that incurs bills these are the steps that must be taken in order to ensure payment and avoid a bad credit rating. Submit ALL BILLS within 15 days from the date of receipt to your team athletic trainer!! Submit your insurance company's "Explanation of Benefits"(EOB) forms indicating that the bill was processed to your team athletic trainer. Without the EOB, the athletic department's insurance company will not make any payments on the bills, making them your responsibility. If you are requesting reimbursement for personal payments made (EXCEPT CO-PAYMENTS), submit original receipts with EOB, indicating that a payment has been made to satisfy a bill to the athletic department. Our team physician is: John Shelton, MD Halifax Family Health Sports Medicine 303 N Clyde Morris Bivd Daytona Beach, FL Phone: (386)

7 INSURANCE CARD Please copy front and back of all insurance cards (prescription, etc.) in the space below

8 STATEMENT DECLARING LACK OF HEALTH INSURANCE I,, of full age and sound mind, do hereby swear: Student-Athlete Printed Name 1. I AM NOT covered under any health insurance policy and I AM NOT covered or named on any other person's health insurance policy. 2. I am not otherwise entitled to health insurance benefits of any kind. 3. I am therefore executing this affidavit in order to receive benefits provided by the secondary insurance policy retained by Bethune-Cookman University. 4. I understand that if, during the course of the school year, I or my family obtains health insurance, that it is my responsibility to notify the athletic training staff and provide them with the policy information and a copy of the front and back of the insurance card. 5. I understand that if it is discovered that a health insurance policy did in fact exist at the time of an injury and/or the time that physician or hospital fees were incurred, that I will be held financially responsible for the bills acquired on my behalf during that time period. ***STOP: THIS FORM MUST BE SIGNED IN FRONT OF THE NOTARY*** Student-Athlete Printed Name: Student-Athlete Social Security Number: Student-Athlete signature: Date: Parent/Guardian signature: Date: Notary of Public: Date: Notary Seal: THIS FORM MUST BE NOTARIZED TO BE VALID

9 HMO GUEST MEMBERSHIP SIGNATURE FORM If you belong to an HMO insurance coverage plan, or other managed care plan, you should contact your employer's benefits provider or your insurance company before your child enters school. If you are unsure of the nature of your medical insurance coverage, contact your employer's benefits provider or insurance company to clarify your coverage. It has been our experience that it would be beneficial for you to contact your insurance company NOW, long before your child enters school in the Fall, to ask the appropriate questions in order to maximize your benefits, and to ensure your child has adequate, hassle-free coverage while he or she is away at school. You may find it necessary for you to change insurance coverage, if your insurance company will not allow out-of-network coverage for your child. If you have any printed material, medical records, or phone number that should be called prior to the student athlete receiving any medical treatment that would assist in this matter, please include them when you return this packet. This worksheet is designed for you to use when you call your insurance company. 1. Can we set up out-of-network coverage for my child while he or she is away at school? Yes No 2. What providers in Daytona Beach, FL are acceptable for my child to see in the event he or she has an injury/illness? (This is once out-of-network coverage is set up.) 3. Does my child need to be certified as a full-time college student to be covered (while away at school)? If yes, will you send the appropriate paperwork? Yes No 4. Are there specific guidelines that must be followed in order to access medical care (out-of-network care) while my child is away at school at Bethune Cookman University in Daytona Beach, 32114? I, hereby verify that I have contacted my insurance company regarding guest membership. I also acknowledged that I have signed up for guest membership. If PPO policy, this does not apply to you (please circle) NOT APPLICABLE If HMO policy, is Guest Membership available to you: Yes No If so, indicate date called: Name of Representative Comments: Student-Athlete Signature: Date: Policy Holder s Signature: Date:

10 MEDICAL EXPENSE INFORMATION The National Collegiate Athletic Association has established guidelines for athletic medical expenses, identifying what is permissible and non-permissible for the institution to pay. Bethune-Cookman University Athletic Department MAY finance the following ATHLETIC MEDICAL expenses: Death/dismemberment insurance for travel with intercollegiate athletics competition and practice Counseling expenses related to eating disorders Special individual expenses resulting from a permanent disability that precludes further athletic participation as determined by BCU Sports Medicine Staff Expenses for medical treatment as a result of an athletically related injury as determined by BCU Sports Medicine Staff Bethune-Cookman University Athletic Department MAY NOT finance the following NON- ATHLETIC MEDICAL expenses: Student health insurance Medical, surgical, hospital or physical therapy expenses to treat non-athletic related illness or injury Medical, surgical, hospital or physical therapy expenses as the result of an injury going to or participating in class (e.g. physical education class) Teeth cleaning, provisional filling of teeth or other dental work, unless the dental work is directly related to an injury to the teeth that occurred during an official practice and/or game. BCU's secondary health insurance policy DOES NOT cover prescription orthotics. Second Opinion/Outside Referral Policy Second opinion physician visits, specialists, diagnostic testing and other services (chiropractic, podiatry, massage therapy, physical therapy, etc...) WILL ONLY BE COVERED by the Bethune- Cookman University Athletic Department IF REFERRED AND APPROVED by the BCU Team Physician and the BCU Athletic Training Staff. Any expenses incurred by the student-athlete without referral from a BCU athletic trainer or BCU Team Physician, WILL BE THE SOLE FINANCIAL RESPONSIBILITY of the student-athlete. I HAVE READ AND UNDERSTAND THE ABOVE MEDICAL EXPENSE INFORMATION. Student-Athlete Printed Name: Student-Athlete signature: Date: Parent/Guardian signature: Date:

11 AWARENESS OF INSURANCE POLICIES The Undersigned (athlete, parent/guardian) herewith, A. Understands that any medical expense incurred due to pre-existing conditions and not directly attributed to athletic participation at Bethune-Cookman University is his/her personal responsibility. B. Understands that the athletic medical insurance is secondary coverage and does not cover him/her until he/she has been cleared by an athletic pre-participation physical evaluation. C. Understands that it is his/her responsibility to report all injuries/illnesses to his/her staff certified athletic trainer as soon as possible. D. Understands that he/she must refrain from practice(s) and /or game(s), per direction of staff certified athletic trainer and/or physician orders, until he/she is discharged from treatment or given permission by the staff certified athletic trainer to restart athletic participation despite continuing treatments. E. Understands that having passed the pre-participation physical evaluation does not necessarily mean he/she is physically qualified to engage in athletics, but only that the evaluator(s) did not find a medical reason to disqualify him/her at the time of the said evaluation. F. Certifies that the above answers are correct and true. Student-athlete signature: Date: Parent/Guardian signature: Date: Upon completion of this form, it is to be reviewed and signed by a staff certified athletic trainer. Certified athletic Trainer: Date:

12 PART I -ACKNOWLEDGEMENT OF RISK ASSOCIATED WITH SPORT PARTICIPATION WARNING: Although participation in supervised intercollegiate athletics and activities may be one of the least hazardous in which student-athletes will engage in or out of school, BY ITS NATURE, PARTICIPATION IN INTERCOLLEGIATE ATHLETICS INCLUDES A RISK OF INJURY WHICH MAY RANGE IN SEVERITY FROM MINOR TO LONG TERM CATASTROPHIC, INCLUDING PERMANENT PARALYSIS FROM THE NECK DOWN OR DEATH. Although serious injuries are not common in supervised intercollegiate athletic activities, it is possible only to minimize, not eliminate the risk. Participants can and have the responsibility to help reduce the chance of injury. STUDENT- ATHLETES MUST OBEY ALL SAFETY RULES, REPORT ALL ATHLETIC INJURIES TO THE ATHLETIC TRAINERS, FOLLOW A PROPER CONDITIONING PROGRAM, AND INSPECT ALL EQUIPMENT DAILY. By signing this form, you acknowledge that you have read and understand this warning. STUDENT-ATHLETES WHO DO NOT WISH TO ACCEPT THE RISKS DESCRIBED IN THIS WARNING SHOULD NOT SIGN THIS PORTION OF THE FORM AND WILL NOT BE ABLE TO PARTICIPATE! Student-athlete signature Date Parent/Guardian signature Date PART II-INFORMATION AND CONSENT FOR TREATMENT I,, hereby give my consent to the medical personnel (Athletic Training Staff, Team Physicians) of Bethune-Cookman University to perform or initiate emergency and first aid treatment as may be necessary for my welfare. This consent is relative 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. I further understand that there are risks of injury or death arising from my participation in intercollegiate sports and that even though proper coaching techniques are used, rules are adhered to, and protective equipment is used, the possibility of an accident still exists. To decrease the risk of injury, I understand that equipment must be worn properly and that I must adhere to all instructions and all rules applying to the sport. I further agree to report to the Equipment Manager, Athletic Trainers, or Coaches any defects, or change of fit, in my athletic equipment. However, I acknowledge that proper use of equipment, proper training and adherence to the rules may not prevent all risk of injury and I assume those risks. I have read and understand the above consents and releases. Student-athlete signature Date Parent/Guardian signature Date

13 AUTHORIZATION AND CONSENT FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION I hereby authorize the physicians, athletic trainers, sports medicine staff and other health care personnel representing Bethune-Cookman University to release information regarding protected health information and related information regarding any illness or injury during participation of athletics at Bethune-Cookman University. I further understand that it is at my request to comply with the requirements of Bethune-Cookman University and the release of health information to a coach, athletic director or school official in connection with participation in intercollegiate sports. This protected information may concern the athlete's medical status, medical condition, injuries, prognosis, diagnosis and/or diagnostic imaging, athletic participation status, and related personally identifiable health information. This protected information may be released to other health care providers, hospital and/or medical clinics and laboratories, athletic coaches, medical insurance coordinators, athletic and/or school administrators. I, give authorization/consent for the disclosure of the above described protected health information as a requirement for participation in intercollegiate athletics at Bethune-Cookman University. I understand that my protected health information is protected by the federal regulations under the health Information Portability and Accountability Act (HIPAA) and may not be disclosed without authorization. I understand that I may revoke this authorization/consent at any time by notifying in writing to the athletic director, but if I do, it will not have any effect on the actions the school officials took in reliance on this authorization/consent prior to receiving the revocation. This authorization/consent expires one year from the date it is signed. A photostatic copy of this authorization/consent shall be considered as effective and valid as the original. Please submit records to: Brian Jansen, ATC/L Head Athletic Trainer Bethune-Cookman College 640 Mary McLeod Bethune Blvd. Daytona Beach, FL Phone: (386) Fax:(386) Student-Athlete Signature: Date: Social Security Number: _ Date: Parent/Guardian Signature: Date: