Averett University
Athletic Training Department
420 W. Main St.
Danville, VA 24541
Dear Incoming Student-Athlete,
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.
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.
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.
3. Physical Exams should be conducted by your personal physician prior to arriving on campus.
a. Only the Averett University Athletic Training Department’s Physical Examination Form will be
accepted, and is included in this packet.
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.
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.
5. TO ENSURE ACCURACY AND TIMELY PROCESSING, ALL PAPERWORK SHOULD BE
SUBMITTED BY JULY 15
TH.
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.
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.
Sincerely,
Thomas Underwood
Thomas Underwood
Head Athletic Trainer
AVERETT UNIVERSITY ATHLETIC TRAINING DEPARTMENT
Pre-Participation Examination Paperwork Checklist
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.
Insurance Form
Insurance Card Copy
Health History
ADHD Medicine Notification Form
Physical Examination
Hemoglobin Solubility Test Result, or other laboratory documentation of sickle cell trait status
Medical Authorization Waiver
Concussion Statement Sheet
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.
Make a copy for your records
Mail Entire Packet in a large, flat envelope to:
Averett University
Athletic Training Dept.
420 W. Main St.
Danville, VA 24541
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
YES
NO
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
NO
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
NO
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
I,
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
th
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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