AVERETT UNIVERSITY ATHLETIC TRAINING DEPARTMENT
Medical Authorization Waiver
I, the undersigned, hereby acknowledge, affirm, and represent the following:
A. PRESENT PHYSICAL CONDITION:
Upon / prior to reporting to Averett University, I completed a Health History Form and was examined by a qualified
physician and/or his/her designee. I hereby affirm that I have fully disclosed in writing my prior medical history; that my
Health History Form was fully and accurately completed; that all of my present symptoms, complaints, ailments,
disabilities, and/or prior injuries have been disclosed in writing to and discussed with a qualified physician and/or his/her
designee; and that I am not suffering from any complaints, prior injuries, ailments, disabilities, conditions, or problems not
so disclosed and discussed. Furthermore, I consent to laboratory analysis, urine screen, blood chemistry, orthopedic,
internal, and any other examination deemed necessary to determine my physical/mental condition.
B. FUTURE COMPLAINTS:
I acknowledge and agree that all future injuries, complaints, re-injuries, and aggravations of old injuries must be
immediately reported to the University’s Team Physician, the Head Athletic Trainer, and/or his/her designee, no matter
how minor or insignificant I may deem them to be. I understand that my responsibility to report injuries and
illnesses includes, but is not limited to, signs and symptoms of concussions.
C. MEDICAL TREATMENT:
I hereby authorize the Averett University team physicians, athletic trainers, and designated medical staff to examine and
treat any injuries, which may occur, while participating in athletics at Averett University. I authorize the team physicians,
athletic trainers, and designated medical staff to communicate with athletic department officials and coaching staff
regarding their findings and recommendations. I further understand that the team physician and/or his/her designee have
the authority to eliminate me from participation as a student-athlete due to an injury/illness, and/or due to undue liability
risk of Averett University.
I understand that any medical conditions and/or injuries incurred must be evaluated and/or treated by Averett University
Athletic Training personnel before a physician referral is made. All medical services must be provided by Averett
University personnel and/or Averett University Team Physicians unless otherwise approved in writing by the Head Athletic
Trainer and/or his/her designee. If I decide to see a physician / medical consultant, and/or undergo a diagnostic test
prior authorization / referral from a member of the Averett University Athletic Training Department, I will be
financially responsible for any and all medical bills incurred.
D. REQUIREMENT OF MEDICAL INSURANCE:
I understand that as a student-athlete at Averett University, I am required be covered by some type of individual health
insurance before participating in any strength and conditioning sessions, practice, game, and/or competition. This
insurance shall be considered the PRIMARY
insurance coverage for all athletic related injuries. I understand I will also be
required to purchase the Averett University Student / Sports Accident Policy prior to participation. I understand that the
Averett University Department of Athletics and NCAA will provide a medical and catastrophic insurance program for
student-athletes injured in practices, games or competitions, and/or related travel that was supervised by approved
University coaching staff and approved by the Director of Athletics according to NCAA regulations. THESE POLICIES,
HOWEVER ARE SECONDARY
TO, OR IN EXCESS OF, THE STUDENT-ATHLETE’S INDIVIDUAL HEALTH
I understand that the Averett University Athletic Training Department must receive any changes to my health insurance
policy as soon as they occur. If proper notification is not received, Averett University may not be responsible for any
delays in payment, collections notices, credit reports, etc. that occur and/or the full account balance.
Should my primary insurance expire during the academic year, it is my responsibility to notify Averett University’s Athletic
Training Staff immediately. I understand I will be removed immediately from participation in intercollegiate athletics until a
new insurance card is provided. Furthermore, I understand Averett University will not be responsible for monitoring the
expiration of my insurance card, or for any medical bills from injuries sustained while I am participating with this expired
card, and the financial responsibility will fall to myself.
I understand that it is my responsibility to understand the conditions that apply to my personal health insurance policy and
comply with any requests for information, etc. from my health insurance company. I understand that any delinquent bills
resulting in bad credit due to non-compliance with insurance company requests may be my responsibility.