Fill - Free fillable Dear Incoming Student-Athlete, (Averett College) PDF form

Averett University

Athletic Training Department

420 W. Main St.

Danville, VA 24541

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Dear Incoming Student-Athlete,

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PLEASE READ ALL INFORMATION CAREFULLY & FILL OUT ALL NECESSARY FORMS. WE

DO NOT WANT ANYTHING TO AFFECT YOUR PARTICIPATION STATUS UPON YOUR

ARRIVAL TO CAMPUS.

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1. All student-athletes must complete the Pre-Participation Packet BEFORE they are permitted to attend any practice,

strength and conditioning sessions, and/or compete in any intercollegiate athletic events.

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2. All student-athletes must also submit a legible photocopy (front & back) of their health insurance card every year.

Cards should be included with the pre-participation packet.

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3. Physical Exams should be conducted by your personal physician prior to arriving on campus.

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a. Only the Averett University Athletic Training Department’s Physical Examination Form will be

accepted, and is included in this packet.

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4. All student-athletes must receive a Hemoglobin Solubility Test, or show other laboratory documentation of

sickle cell trait status, regardless of ethnicity. If you have not previously been tested you should have testing done

during your physical.

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This documentation must be on file within the Athletic Training Department BEFORE a student-athlete is

permitted to participate in any intercollegiate athletics activity, including any strength and conditioning

workouts, walk-through, practices, competitions, etc.

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5. TO ENSURE ACCURACY AND TIMELY PROCESSING, ALL PAPERWORK SHOULD BE

SUBMITTED BY JULY 15

TH.

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If you have any questions or concerns regarding the Pre-Participation Packet and/or general sports medicine questions,

please do not hesitate to contact the Athletic Training Department, or your team coach.

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Thank you for your time and consideration in completing these important tasks. We wish you the best of luck throughout

the summer and are looking forward to seeing you in August.

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Sincerely,

Thomas Underwood

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Thomas Underwood

Head Athletic Trainer

AVERETT UNIVERSITY ATHLETIC TRAINING DEPARTMENT

Pre-Participation Examination Paperwork Checklist

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This form has been designed to be used as a checklist for submitted required documentation. The student-athlete is

responsible for attaining medical testing, forwarding all required documents, and ensuring their arrival.

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Insurance Form

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Insurance Card Copy

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Health History

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ADHD Medicine Notification Form

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Physical Examination

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Hemoglobin Solubility Test Result, or other laboratory documentation of sickle cell trait status

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Medical Authorization Waiver

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Concussion Statement Sheet

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If your insurance is an HMO or requires pre-authorization (such as Tri-Care Prime), we strongly encourage you to check if

you are covered in the Danville area. If not, we recommend you explore the advantages and disadvantages of changing

the primary care physician (PCP) to an Averett University or local physician. This may allow you to have a network of

physicians in the area, as well as quicker access to care.

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Make a copy for your records

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Mail Entire Packet in a large, flat envelope to:

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Averett University

Athletic Training Dept.

420 W. Main St.

Danville, VA 24541

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Attn: Thomas

Underwood

AVERETT UNIVERSITY

Health Insurance Information / Authorization

(Please fill out electronically or print clearly in BLACK INK ONLY!)

First Name Last Name Middle Initial

Date of Birth Social Security No

Sex: Male Female Sport

Permanent Address

City State Zip

Home Phone Cell Phone

Will you be purchasing Primary Insurance through Averett University? NO YES

Insurance Company Policy Holder

Address Policy Holder’s DOB

City State Zip Policy Holder’s Address (If different from permanent address)

Phone Number Street

Type of Insurance- City State Zip

HMO PPO POS Military Policy / ID #

Other Group #

PLEASE READ CAREFULLY!

♦ Averett University & the Department of Athletics’ accident policy provides insurance for student-athletes with injuries occurring only when

participating in the play or practice of intercollegiate athletics. This accident policy is considered “EXCESS” or “SECONDARY” to any other

collectible group insurance benefits. Therefore, any claims for benefits must first be filed with the group insurance company providing coverage.

Only after all available benefits have been exhausted will Averett University’s & Department of Athletics’ insurance carrier consider payment for any

remaining balances.

♦ I hereby authorize Averett University & the Department of Athletics, hospitals, & physicians connected with or provided, to furnish information to

insurance carriers concerning any illness, injury, & treatments & I hereby assign to the party all payments for medical services rendered to the

student-athlete.

♦ I agree to supply any & all information requested by my primary insurance, Averett University & the Department of Athletics & their excess

insurance company in a timely manner.

♦ I hereby authorize the Averett University & the Department of Athletics and their excess insurance company to secure & inspect copies of case

history records, lab reports, diagnoses, x-rays, & any other data pertaining to the injury/illness I am receiving care for or previous confinements of

disabilities relevant to the care of the injury/illness.

♦ I hereby authorize Averett University and/or the Athletic Training Department and/or my coach to hospitalize & secure treatment for me for any

athletic injury/illness.

♦ A photocopy of this authorization shall be deemed as effective & valid as the original.

♦ I agree to notify Averett University and/or the Athletic Training Department immediately upon any change in the above health insurance information.

If I fail to do so, I fully understand that I may be responsible for any & all charges incurred.

♦ I hereby certify that I have read & understand the above statements, that any & all questions have been answered to my satisfaction, & that the

answers provided are true, complete, & correct to the best of my knowledge.

______________________________________________ __________________________

Student-Athlete Signature Date

_______________________________________________ __________________________

Parent/Guardian Signature (if under 18 years of age) Date

STUDENT INSURANCE INFORMATION

(If not purchasing through Averett University)

Please attach a copy of the insurance card on the appropriate box with tape (DO NOT STAPLE). Failure to attach copy will result in an

incomplete insurance form.

FRONT OF INSURANCE CARD

BACK OF INSURANCE CARD

AVERETT UNIVERSITY

Student Health History Questionnaire

The information contained in this medical history form will only be used by Averett University for purposes of determining if you pose a

health threat / risk to yourself in the class room or on the athletic field. This information will remain CONFIDENTIAL

at all times.

First Name Last Name Middle Initial

Date of Birth

Emergency Contact Name Relationship

STREET CITY STATE ZIP CODE

PHONE 1 PHONE 2 (CELLULAR)

Have you EVER had the following medical General Medical conditions?

YES

Marfan’s Sydrome

Rheumatic Heart Disease

Sickle Cell Trait / Sickle Cell

Anemia

Tuberculosis

Diabetes

Bleeding Disorder

Seizure Disorder / Epilepsy

Hearing Defect / Loss

Chronic / Allergic Asthma, and

/or Exercise Induced Asthma

Mental Health Issue

Rheumatic Fever

Been recently diagnosed with infectious mononucleosis (“mono”), hepatitis B or C, HIV/AIDS, and/or any

other severe infectious disease / viral infection?

Had an unfavorable / allergic reaction to a food / food product, drug / medication, insect bite / bee sting, etc?

Do you require use of an Epi-Pen Auto Injector?

Do you have a complete and functional set of paired organs (i.e. kedneys, testicles, ovaries, eyes, etc.)

Prescription Medications:

Please List ALL Prescription Medications That You Are CURRENTLY Taking & For What Purpose:

MEDICATION PURPOSE DOSAGE

Immunizations

MMR (Measles, Mumps, and Rubella) Date Completed:

Tetanus Toxoid (Must be within 10 years) Date Completed:

Tuberculosis Skin Test Date Completed:

- Or Chest X-Ray Date Completed:

Meningitis (Required by all incoming students) Date Completed:

Verification of Immunization Record (Not required for returning students if there have been no changes)

_____________________________________________________

Signature of Certified Medical Practitioner

_____________________________________________________

Name of Medical Facility

_____________________________________________________

Facility Telephone Number

Have you EVER had the following?

YES

Cardiovascular Risk Factors

Chest pain / discomfort / shortness of breath during or after exercise / practice

Unexplained dizziness, fainting or near fainting , or “blacking out” during or after exercise / practice

Diagnosed with a heart murmur

High Blood Pressure

One or more relatives who died of heart disease before age 50

Close relative under age 50 with disability from heart disease

Family history of inherited cardiac conditions (i.e. cardiomyopathy, long QT syndrome, ion channelopathies, or clinically relevant arrhythmias)

Are you being seen by a cardiologist (heart specialist) presently

YES

Orthopedic / Sports History

Had a sprain, strain, tear, or fracture to any ligament / muscle / tendon / bone?

Had a concussion and / or head injury?

Had a neck / C-Spine injury?

Had a back injury or suffered from back pain?

Do you currently have numbness / tingling / burning in the neck, shoulder, hand, leg, or foot?

Had any of “burners” or “stingers”?

Had a shoulder, elbow, and/or hand / wrist injury?

Had a hip and/or knee injury?

Had a lower leg, ankle, and/or foot injury?

Do you require any special equipment to participate in athletics (i.e. knee braces, protective eyewear, etc.?)

Had a heat related illness (heat cramps, heat exhaustion, and/or heat stroke) and/or missed time / received special attention (IV fluids, etc.) for a heat

related problem?

FEMALE ATHLETES ONLY!

When did your last menstrual period begin?

How long does your menstrual period usually last?

How many menstrual periods have you had in the last 12 months?

Do you take birth control pills? If so, which one(s)?

Do you take pain medication? If so, which one(s)?

If you answered “YES” to any of the above questions, please explain in detail, with dates, below (use additional sheet(s) if necessary)-

I, the undersigned, hereby acknowledge, affirm, and represent that all above statements are true and accurate to the best of my knowledge; and that no

answers or information have been withheld. If any information and/or statements are false and/or have been omitted in reference to my past and/or

present medical history, I understand and acknowledge that my health and physical welfare may be jeopardized as a result and that I may suffer physical

harm.

______________________________________________ __________________________

Student Signature Date

_______________________________________________ __________________________

Parent/Guardian Signature (if under 18 years of age) Date

AVERETT UNIVERSITY ATHLETIC TRAINING DEPARTMENT

ADHD Medical Exceptions Notification Form

affirm that I have been informed by Averett University Athletic Training

Student-Athlete Print Name

personnel on

about the NCAA Banned Substances List and NCAA Medical Exceptions

Date

Policy as it specifically pertains to the use of banned stimulant medications

(e.g. Ritalin, Stattera, Adderall,

Concerta, etc.) that are used to treat Attention Deficit Hyperactivity Disorder

(ADHD), Attention Deficit Disorder

(ADD), or like conditions. I attest that:

I AM NOT presently taking and/or have taken within the last 12 months any

banned stimulant medications (e.g. Ritalin, Stattera, Adderall, Concerta, etc.) that

Initial___________________ are used to treat Attention Deficit Hyperactivity Disorder (ADHD), Attention Deficit

Disorder (ADD), or like conditions.

I AM presently taking and/or have taken within the last 12 months banned

stimulant medications (e.g. Ritalin, Stattera, Adderall, Concerta, etc.) that are

used to treat Attention Deficit Hyperactivity Disorder (ADHD), Attention Deficit

Initial_________________ Disorder (ADD), or like conditions.

Medication & Dosage

I, the undersigned, do hereby affirm that I understand that I am to immediately notify a member of the Averett

University Athletic Training Department should I ever be prescribed the aforementioned stimulant medications

and that I must obtain and submit appropriate documentation from the prescribing physician.

I further attest that I have had any and all questions regarding the NCAA ADHD Medical Exceptions Policy

answered to my satisfaction, and agree to submit all necessary documents to the Averett University Athletic

Training Department before the post-season, as this will result in removal from competition until on file.

______________________________________________ __________________________

Student-Athlete Signature Date

_______________________________________________ __________________________

Parent/Guardian Signature (if under 18 years of age) Date

AVERETT UNIVERSITY ATHLETIC TRAINING DEPARTMENT

Medical Examination for Intercollegiate Athletics

(Form must be completed in English)

This is a screening examination for participation in sports. This does not substitute for a comprehensive examination with your regular

physician where important preventive health information can be covered.

Name Class: FR SO JR SR 5

Year

Social Security #

Date of Birth Sex: Male Female

Sport(s):______________________________

The following is to be completed by a physician or their designee

Height:______________ Weight:______________ Blood Pressure: ____________ Pulse:____________

Eyes: (Corrected/Uncorrected) Right:______________ Left:______________

NORMAL

ABNORMAL FINDINGS

Heart / Cardiovascular

Pulmonary / Lungs

Abdomen / Gastrointestinal

Musculoskeletal Review

Neurological

Evaluation of Medical

Problems since last exam

Recommendations / Comments:

Status:

Cleared For Participation

Not Cleared For Participation

Further Evaluation Needed

Physician’s Name & Address: _________________________________________________________________________

Telephone: ( ) ______________________Fax: ( ) ___________________________

Examiner’s Signature Date

Examiner Print Name

Sickle Cell Trait Testing

Averett University requires all athletes to undergo a Hemoglobin Solubility Test, or show other laboratory documentation of

sickle cell trait status, regardless of ethnicity. If you have not previously been tested you should have testing done during your

physical. Averett University will not allow any student to participate in athletics until we have sickle cell test results on file in the athletic

training room.

Please attach the results to this physical form

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

without

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

INSURANCE.

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.

I understand that in the event that I and/or my parent(s) / guardian(s) receives payment / reimbursement directly from my

insurance company for an injury / illness that occurred as a direct result of participation in intercollegiate athletics at

Averett University, the full account balance becomes my responsibility until payment is turned over to the provider

or Averett University

I understand that I must submit all correspondence from an insurance company (i.e. statement, invoice, bill, explanation of

benefits {EOB}, insurance documentation, etc.) for any injury and/or illness that occurred as a direct result of my

participation in intercollegiate athletics at the Averett University in a timely manner. Documents not received by the

Averett University Athletic Training Department in a timely manner may be my responsibility. Averett University WILL

NOT be responsible for any delays in payment, collections notices, credit reports, etc. that occur due to

documents not being submitted in a timely manner.

E. AGREEMENT TO PARTICIPATE:

I am aware that playing, practicing, training, and/or other involvement in any sport can be a dangerous activity involving

MANY RISKS OF INJURY, including, but not limited to the potential for catastrophic injury. I understand that the dangers

and risks of playing, practicing, or training in any athletic activity include, but are not limited to, death, serious neck and

spinal injuries which may result in complete or partial paralysis or brain damage, serious injury to virtually all bones, joints,

ligaments, muscles, tendons, and other aspects of the muscular-skeletal system, and serious injury or impairment to other

aspects of my body, general health and well-being. Because of the aforementioned dangers of participating in any

athletic activity, I recognize the importance of following all instructions of the coaching staff, strength and conditioning

staff, and/or Athletic Training Department. Furthermore, I understand that the possibility of injury, including catastrophic

injury, does exist even though proper rules and techniques are followed to the fullest. I also understand that there are

risks involved with traveling in connection with intercollegiate athletics.

In consideration of Averett University permitting me to participate in intercollegiate athletics and to engage in all activities

and travel related to my sport, I hereby voluntarily assume all risks associated with participation and agree to hold

harmless, indemnify, and irrevocably and unconditionally release Averett University, and their officers, agents, and

employees from any and all liability, any medical expenses not covered by Averett University’s medical insurance

coverage, and any and all claims, causes of action or demands of any kind and nature whatsoever which may arise by or

in connection with my participation in any activities related to intercollegiate athletics.

The terms hereof shall serve as release and assumption of risk for my heirs, estate, executor, administrator, assignees,

and all members of my family.

F. AUTHORIZATION:

I fully understand that this authorization shall be effective and valid for one year (52 weeks) after the termination of my

playing and/or academic career at Averett University.

I hereby attest that I have read and fully understand the Averett University Athletic Training Department’s Medical

Authorization Waiver. Further, I agree to abide by all the requirements set forth for the duration of my playing career, and I

understand that failure to abide by the requirements could result in unfavorable health consequences, or financial burden

to myself.

______________________________________________ __________________________

Student-Athlete Signature Date

_______________________________________________ __________________________

Parent/Guardian Signature (if under 18 years of age) Date

AVERETT UNIVERSITY ATHLETIC TRAINING DEPARTMENT

Student-Athlete Concussion Statement

After reading the NCAA Concussion fact sheet, I am aware of the following information:

• A concussion is a brain injury, which I am responsible for reporting to my team physician or athletic trainer.

• A concussion can affect my ability to perform everyday activities, and affect reaction time, balance, sleep, and

classroom performance.

• You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show

up hours or days after the injury.

• If I suspect a teammate has a concussion, I am responsible for reporting the injury to my team physician or

athletic trainer.

• I will not return to play in a game or practice if I have received a blow to the head or body that results in

concussion-related symptoms.

• Following concussion the brain needs time to heal. You are much more likely Initial to have a repeat concussion if

you return to play before your symptoms resolve.

• In rare cases, repeat concussions can cause permanent brain damage, and even death.

______________________________________________ __________________________

Student-Athlete Signature Date

_______________________________________________ __________________________

Parent/Guardian Signature (if under 18 years of age) Date

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