Download Authorization to Release Information-Part III

Atlantic Armstrong State University Sports Medicine
Welcomes You!
Welcome to intercollegiate athletics at Armstrong Atlantic State University. We hope that your time
here will be among the best years of your life. The Armstrong Atlantic State University Sports
Medicine Staff is here to help make your athletic endeavors enjoyable and safe. 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 Armstrong Atlantic State University.
Please read and complete all of the documents that are enclosed.
You must have a completed Athlete/Insurance form with your personal insurance information
before you are allowed to participate in any athletic activity (including try-outs). A copy (front and
back) of your insurance card is mandatory. If you need assistance in finding a valid health
insurance plan, please contact the Head Athletic Trainer.
Armstrong Atlantic State University’s athletic insurance policy is described in detail in the following
pages. If you have any questions or concerns regarding any of the following forms, please contact
the Armstrong Atlantic State University Athletic Training Room at (912) 344-2866. Thank you for
your assistance in this matter. We look forward to working with you in the future.
Sincerely,
AASU Sports Medicine Staff
St. Joseph’s/Candler Sports Medicine
11935 Abercorn St.
Savannah, GA 31419
912-344-2866
912-344-3420 fax
Armstrong Atlantic State University
Intercollegiate Athletics
Pre-Participation Physical Screening Evaluation
Name:____________________________________________________ Gender: M
F
Age: _____________
D.O.B. _____/_____/_____
Date of Exam: __________________
History: Please circle yes or no. Explain all Yes answers in the given space below.
1. Do you have any on going medical conditions?
2. Have you ever spent the night in the hospital?
3. Have you ever had surgery?
4. Have you ever had discomfort/pain in your chest while exercising?
5. Has a doctor ever told you that you have heart problems?
6. Has a doctor ever ordered a test for your heart?
7. Have you ever had an unexpected seizure?
8..Has any family member or relative died of heart problems or had an
unexpected or unexplained sudden death before age 50?
9. Does anyone in your family have hypertrophic cardiomyopathy?
10. Does anyone in your family have a heart problem?
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
11. Have you ever had a broken or fractured bone(s) or
dislocated joints?
12. Have you ever had a stress fracture?
13. Do you regularly use a brace, orthothotics, or other
assistive device?
14. Have you ever used an inhaler or take asthma
medicine?
15. Have you ever had a head injury or concussion?
16. Do you or someone in your family have sickle cell
trait disease?
17. Have you ever had numbness, tingling, or weakness
in your arms or legs after being hit or falling?
18. Have you ever been unable to move your arms or
legs after being hit or falling?
19. Have you ever become ill while exercising in the
heat?
20. Have you ever had herpes or MRSA infection?
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Explain all Yes answers: ______________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are
currently taking: ________________________________________________________________________________________________________________________________________________________
Do you have any allergies?
Yes No If yes, please identify specific allergy:____________________________________________________
Examination: For Doctor’s Use
Height: _______’_______”
Left Eye: __________/__________
Weight: __________lbs.
Blood Pressure: __________/__________
Right Eye: __________/___________
Normal
Pulse: ___________bpm
Both Eyes: __________/___________
Abnormal
Initials
Neck
Shoulder
Elbow
Wrist
Hand
Back
Knee
Ankle
Foot
Hamstring Flexibility
Reflexes
Heart
Lung
Longitudinal Arch – Circle One:
Present
Evidence of Marfan’s – Circle One:
Present _____________________________________________________________
Sickle Cell Trait:
Negative
Positive
Absent
Absent
Waived
Participation Status:
_____________ Full Unlimited Participation in Intercollegiate Athletics
_____________ Limitations (Explain) ___________________________________________________________________________________________________________________________________
_____________ Participation withheld until (Explain) _______________________________________________________________________________________________________________
Physician’s Signature: _________________________________________________________________________
2
Examination Date: _______________________________________
Armstrong Atlantic State University Sports Medicine
General Athlete Information – PLEASE PRINT
Athlete’s Name: ________________________________________________________________
Last
First
Sport(s):______________________________
MI
Social Security Number: _______________________________________________________
D.O.B: _________/__________/__________
School Address: ________________________________________________________________
Cell Phone: ________-________-_________
________________________________________________________________
Athletic Year: Fr Soph Jr
Sr
Parent/Guardian Name: __________________________________________________________________
Parent/Guardian Address: __________________________________________________________________________________________________________
Street
City
State
Zip
Parent/G Home Phone: __________-___________-__________
Parent/G Cell Phone: __________-__________-___________
Another Emergency Contact Name: ______________________________________________________ Number:_________-__________-_________
Health Insurance Information – PLEASE PRINT
Fill out the following information and provide a legible copy of the insurance card (Front/Back)
Name of Insured: ________________________________________________________________
Last
First
MI
Relationship to Athlete: ________________________________________
Insured’s SSN: __________-_________-___________
Insured’s Employer: _________________________________________
Insurance Company: ____________________________________________________________
Insured DOB: ______/______/______
Insurance Co. Address: ______________________________________________________________________________________________________________
Street
City
State
Zip
Insurance Co. Phone: _________-__________-__________
Deductible Amt:______________________________________________________
Policy/ Number: _______________________________________________
Group Number: ________________________________________________
I.D. Number: __________________________________________________
Does your insurance plan include prescription medication coverage? ____________Yes
_____________No
*If you answered yes, which pharmacy can be used (Wal-Mart, Lo-Cost, CVS, etc)? _________________________________
Primary Physician Name: ___________________________________________________
Number: __________-__________-____________
**A COPY OF THE INSURANCE CARD (FRONT AND BACK)
MUST BE INCLUDED WITH THIS FORM AND ON FILE IN THE
ARMSTRONG ATLANTIC STATE UNIVERSITY ATHLETIC TRAINING ROOM**
3
Armstrong Atlantic State University
Athlete’s Medical History
Has any blood relative ever had? Circle Yes or No and identify their relationship to the athlete.
Sudden death (before age of 55)
Cancer
Blood Disease (sickle cell, leukemia, etc)
Diabetes
Epilepsy
Gout
Heart Disease
Hypertension (high blood pressure)
Hemophilia
Marfan’s Syndrome
Mental Disorders
Stroke
Tuberculosis
Alcohol/Drug Dependency
Is your immunization record complete?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
General Medical Health History
Have you ever had any of the following conditions?
Abnormal bruising
Abnormal bleeding
Anernia
Blood clots
Blood disease
Blood in urine
Diabetes
Birth defects
Heart troubles
Hypertension
Sickle cell anemia/trait
Marfan’s
Goiter/Thyroid Disorder
Chronic Fatigue
Asthma
Bronchitis
Exercise Induced Asthma
Motion sickness
Pneumonia
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Migraine headaches
Frequent headaches
Loss of memory
Concussion
Seizure disorder
Epilepsy
Cancer
Liver disease
Tumor, cyst, growth
Hearing defect/loss
Visual defect/loss
Disordered eating
Nervous stomach
Ulcer
Gastrointestinal bleed
Constipation (frequent)
Hemorrhoids
Kidney problems
Bladder infections
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Skin disorder
Muscular disorder
Joint inflammation
Arthritis
Nose fracture
Appendicitis
Hernia
Ruptured organ
Mononucleosis
Tuberculosis
Meningitis
Hepatitis
Herpes (genital/oral)
STDs
HIV/ARC
Polio
Chicken Pox
Mumps
Measles
Do you CURRENTLY have any of the following symptoms or problems?
Frequent headaches
Vision changes
Poor concentration
Ringing in ears
Anxious worry
Excessive worry
Chest pain
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
Loss of energy
Loss of appetite
Increase of appetite
Trouble sleeping
Breathing difficulty
Recurring cough
Sinus congestion
Y
Y
Y
Y
Y
Y
Y
4
N
N
N
N
N
N
N
Sore throat
Muscle cramps
Abdominal pain
Frequent diarrhea
Rectal bleeding
Frequent nausea
Frequent vomiting
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
General Medical Health History Continued
Drug, Food, and Miscellaneous Agents
Please check the appropriate space according to YOUR use of the following substances:
Viatmins
Diet pills
Sleeping pills
Laxatives
Alcoholic beverages
Anti-histamines
Anti-inflammatories
(i.e. Aleve, Advil, Motrin)
Caffeine
Tobacco
Creatine supplements
Metabolic stimulants
Nutritional supplements
Other products
Never
________
________
________
________
________
________
________
Rarely
________
________
________
________
________
________
________
Occasionally
_________
_________
_________
_________
_________
_________
_________
Frequently
_________
_________
_________
_________
_________
_________
_________
________
________
________
________
________
________
________
________
________
________
________
________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
Do you take any medications on a regular basis?
YES
NO
If yes, please list those medications: ________________________________________________________________________________________
Internal
Were you born with a complete-functional set of paired organs?
(eyes, ears, kidneys, lungs, ovaries/testes)
YES
NO
If not, which organs were involved? ___________________________________________________________________________________________
Have you ever had surgery to repair any organ?
(appendix, tonsils, spleen, hernia, etc.)
YES
NO
If yes, please list the reason for surgery, the date, and the physician’s name and address below.
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
Cardiac
Have you ever….?
Felt dizzy, light headed and/or passed out during/after exercise? YES
NO
Had chest pain while exercising?
YES
NO
Had heart palpitations or irregular heartbeat?
YES
NO
Been told you have a heart murmur?
YES
NO
Been seen by a heart specialist?
YES
NO
Had an echocardiogram?
YES
NO
Had a heart stress test?
YES
NO
If you answered Yes, to any of the above questions please explain below:
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
If you answered Yes, to any of the above questions have you been cleared for athletics by your heart specialists?
Yes
No
Do you have written verification of clearance on file in the AASU athletic training room?
Yes
No
5
HEAT
Have you ever experienced any of the following?
Heat cramps (fluid loss from excessive heat)
YES
Trouble with dehydration (excess fluid loss)
YES
Heat Stroke
YES
Heat intolerance
YES
NO
NO
NO
NO
Explanation
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
NO
NO
NO
NO
NO
If yes, date of last exam: ______/_______/________
Eye doctor’s name: _______________________________
Do you wear contacts?
YES
NO
Do you have normal color vision? YES
NO
Do you have a false eye?
YES
NO
VISION
Have you ever been to an eye doctor?
Do you wear eye-glasses?
If yes, for reading only?
Do you wear glasses to participate in athletics?
Have you ever had an eye injury?
YES
YES
YES
YES
YES
If yes, please give details and explain? _______________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
DENTAL
Do you have or have ever experienced the following?
Do you have a bridge or false tooth?
YES
Fractured (broken) a tooth?
YES
Had a tooth knocked out?
YES
Wear orthodontics appliances?
YES
Wear a mouth protector?
YES
NO
NO
NO
NO
NO
Explanation
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
ALLERGIES
Are you allergic too…?
Aspirin
Codeine
Penicillin
Sulfur Compounds
Anti-inflammatories
Hay Fever
Latex
Insect bite/sting
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
Tetanus Serum
Anesthetics
Novocain
Cortisone
Cosmetics
Any food
Chalk/lime
Food Allergies
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
Please explain, and list reactions: _____________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
6
Orthopedic History Questionnaire
Please circle Yes or No. If yes, please explain and give approximate date of injury.
Have you ever injured or consulted a doctor about an injury to any of the following areas:
HEAD/NECK
Unconsciousness
Concussion
Headaches
Burners/Stingers
Fractures
X-rays
MRIs, CT, Bone Scan
Hospitalized
Surgery
Other
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
DATE/EXPLANATION
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
LOWER BACK
Sprain/Strain
Disc Injury
Numbness/weakness
Fracture
X-rays
MRIs, CT, Bone Scan
Hospitalized
Surgery
Other
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
DATE/EXPLANATION
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
SHOUDLER
Sprain/Strain
A-C Joint separation
Dislocation
Shoulder “slips out of place”
Tendonitis
X-rays
MRIs, CT, Bone Scan
Hospitalized
Surgery
Other
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
DATE/EXPLANATION
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
ELBOW /ARM
Sprain/Strain
Tendonitis
Bursitis
Fractures
X-rays
MRIs, CT, Bone Scan
Surgery
Other
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
DATE/EXPLANATION
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
WRIST/HAND/FINGER
Sprain/Strain
Tendonitis
Fracture
X-rays
MRIs, CT, Bone Scan
Surgery
Other
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
DATE/EXPLANATION
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
7
PELVIS/HIP
Dislocation
Fracture
X-rays
MRIs, CT, Bone Scan
Surgery
Other
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
DATE/EXPLANATION
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
LEG/KNEE
Sprained ligaments
Torn cartilage
Tendonitis
Injections/Drainage
Fracture
X-rays
MRIs, CT, Bone Scan
Surgery
Other
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
DATE/EXPLANATION
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
ANKLE/FOOT
Sprain/Strain
Tendonitis
Orthotics
Dislocation
Stress fracture
Fracture
X-rays
MRIs, CT, Bone Scan
Surgery
Other
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
DATE/EXPLANATION
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Have you had or do you have any other medical conditions not listed on this form?
Do you have any health/medical conditions for which you are currently receiving treatment?
Is there any reason for which you would be unable to participate in athletics?
Have you ever been advised by a physician to not participate in athletics or physical activity?
Are there any health conditions you would prefer to discuss privately with our team physician?
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
If you answered yes to any of the above questions, please explain below:
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
8
Athletic Department Policies
1.
Student-athletes are required to have a primary insurance policy. Student-athletes will not be
able to participate in any team athletic related function until the Athletic department has a copy of their
insurance card on file.
2.
Student-athletes will use their own personal insurance with all claims (personal policy
limitations vary by insurance company). The primary insurance is usually a group health plan carried by a
parent’s/guardian’s workplace. It is your responsibility to ensure that all bills are filed through that
primary insurance. We will assist with this task if requested.
3.
AASU carries a secondary policy on each student-athlete through Bob McCloskey Insurance.
This policy AASUres secondary coverage for injuries to athletes while participating in “intercollegiate sports.”
In order for the secondary coverage to apply, the athletic training staff must arrange any medical care
used by the athlete. Once the primary insurance benefits are exhausted, the student athlete must obtain an
Explanation of Benefits (EOB) form from their insurance company and deliver it to the athletic training staff.
Each student-athlete has a $2,000.00 disappearing deductible, which is met through payments by the
student-athlete’s primary insurance and out-of-pocket payments made by the parent/guardian. It is possible that you
may left with a bill up to $2,000 because your bills did not meet our secondary deductible.
Cases that will not be covered by secondary insurance:
-off-season injuries
-self-referrals to outside physicians
-accidents
-illnesses
-pre-existing conditions not related to a supervised practice or intercollegiate sport
4.
Student-athletes are responsible for the purchase of medication (OTC or prescription) either
through their primary insurance or out-of-pocket. In extreme cases of need, you son/daughter should
communicate with his/her coach, the athletic director, and athletic trainer for other options.
9
PARENTS YOU MAY KEEP THIS PAGE FOR YOUR RECORDS
Armstrong Atlantic State University Athletic Medical Insurance Policy
The Armstrong Savannah State University Athletic Department utilizes a secondary athletic medical insurance
policy. Any intercollegiate student-athlete who sustains an athletic-related injury or illness will have medical
claims filed with their parents/guardians private health insurance as the primary insurance provider.
 Once the primary insurance benefits are exhausted, the student athlete must obtain an Explanation of
Benefits (EOB) form from their insurance company and deliver it to the athletic training staff. The
athletic departments’ secondary insurance may be responsible for those remaining expenses not covered
by the primary insurance company if all procedures are followed precisely and in a timely manner. It
must be noted that each student athlete has a $2,000 deductible with the secondary insurance provider.
You may be left with a bill (up to $2,000) if you do not meet the secondary insurance deductible.
 It should be noted that the athletic department may only cover injuries sustained during Armstrong
Atlantic State University Intercollegiate Athletics supervised/authorized practices or games. Also, if a
student athlete insurance carrier drops them, it’s the student athlete’s responsibility to notify the sports
medicine staff immediately and options for new primary insurance can be determined. If this is not
done and the student athlete is injured, AASU will not be responsible for medical bills sustained at time
of injury.
 Additionally, the secondary insurance will only be filed when the student-athlete reports the injury to one of
the AASU 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 Armstrong Atlantic State University Athletic Department, nor is it legal for the athletic
department to AASUme such responsibility. The AASU Athletic Training Staff will arrange medical
appointments for the student-athletes. The Armstrong Atlantic State University Athletic Department nor
its insurers will be financially responsible for payment of unauthorized appointments.
The National Collegiate Athletic Association has established guidelines for athletic medical expenses, identifying
what is permissible and non-permissible for the institution to pay.
Armstrong Atlantic State University Athletic Association may finance the following ATHLETIC MEDICAL
expenses:
-Athletic Medical Insurance
-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
-Expenses for medical treatment as a result of an athletically related injury.
-Medication and physical therapy utilized by a student-athlete during the academic year to enable them to participate
in intercollegiate athletics
Armstrong Atlantic State University Athletic Association 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)
-Routine dental or vision care
-AASU’s secondary health insurance policy DOES NOT cover prescription orthotics. Need for this medical device
will be handled on a case by case basis.
-Purchase of medication (OTC or prescription)
If you should have any questions regarding the Armstrong Atlantic State University Athletic Medical Insurance
Policy, please call Armstrong Atlantic State University Head Athletic Trainer at (912) 344-2866.
10
SECOND OPINION/REFERAL OUT POLICY
Second opinion physician visits, specialists, diagnostic testing and other services (chiropractic,
podiatry, massage therapy, physical therapy, etc…) may only be covered by the Armstrong Atlantic State
University Athletic Association if referred and approved by the AASU Team Physician and the AASU Athletic
Training Staff. Any expenses incurred by the student-athlete without referral from an AASU athletic trainer
or AASU Team Physician will be the sole financial responsibility of the student-athlete.
I HAVE READ AND UNDERSTAND THE ABOVE MEDICAL EXPENSE INFORMATION.
______________________________________
Parent Signature (IF under 18)
______________
Date
______________________________________
Student-Athlete Signature
______________
Date
STATEMENT OF INSURANCE UNDERSTANDING
I ____________________________ have been informed and understand the limits of personal injury
insurance carried on me by the Armstrong Atlantic State University Athletic Department.
I understand that it is required of me to provide proof of primary health insurance to the athletic
department. The Athletic Department Policy will pick up payments after the $2000 disappearing
deductible as been reached. The secondary policy does not cover pre-existing injuries, injuries
sustained outside of athletic participation, and general illness. The secondary policy has a cap of
$90,000.00 per injury. AASU is also a participant in the NCAA Catastrophic Athletics Injury Insurance
Program, this applies for claims above $90,000 within two years of injury. At any time there is a change
in my primary insurance I will notify the athletic department of any change that has taken place.
Parent ___________________________________
Date______________
Student-Athlete ______________________________________
11
Date_____________
Acknowledgement of Risk Associated with Sport Participation-Part I
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. STUDENTATHLETES 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. STUDENTATHLETES 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 Printed Name
______________________________________________
Student-Athlete Signature
______________________________________________
Today’s Date
_________________________________________________
Parent/Guardian Signature
If under 18 yrs. of age, parent/guardian
MUST SIGN
Medical Consent-Part II
I hereby grant permission to the Armstrong Atlantic State University team physicians and/or the Armstrong
Atlantic State University Athletic Training Staff to provide medical care to myself in the event that I become
injured while participating in intercollegiate athletics. I understand that any treatment or medical or
surgical care that is provided to me will be done only if it is considered medically necessary for my health
and well being.
______________________________________________
___________________________________________________
Student-Athlete Printed Name
Parent/Guardian Signature
______________________________________________
If under 18 yrs. of age, parent/guardian
Student-Athlete Signature
MUST SIGN
______________________________________________
Today’s Date
Authorization to Release Information-Part III
I hereby authorize and request AASU and St. Joseph’s/Candler athletic trainers and/or their consulting
physician(s) to furnish any and all requested information to St. Joseph’s/Candler and/or Optim Health, P.C.
physicians, University coaches and administration, professional teams, their agents, scouts, or athletic
trainers which directly pertains to my athletic participation in athletics at AASU. Said authorization shall
include, but is not limited to: information concerning my physical condition, illnesses, injuries, treatments,
hospitalizations, examinations, X-rays, or other forms of diagnostic testing. I hereby fully discharge all
parties to whom this authorization extends from any and all penalties of breach student-athlete
confidentiality. This authorization period is effective until I am no longer an active athlete at AASU.
Additionally, I understand that an additional release form may be required to release information to outside
entities in the event that an injury occurs outside of Savannah, Georgia.
______________________________________________
Student-Athlete Printed Name
_______________________________________________________
Student-Athlete Signature
______________________________________________
Today’s Date
____________________________________________________
Parent/Guardian Signature
If under 18 yrs. of age, parent/guardian
MUST SIGN
12
Student Athlete Sickle Cell Trait To-Do
The NCAA is mandating that all student-athletes must be tested for sickle cell trait, show proof of a
prior test or sign a waiver releasing the Institution of liability if they decline to be tested. In
accordance with this legislation, the Armstrong Atlantic State University Sports Medicine Department
is mandating that all student-athletes must be tested for sickle cell trait, show proof of a prior test or
sign a waiver releasing the State of Georgia, the University, its officers, employees and agents from any
and all costs, liability, expense claims, demands or causes of action on account of any loss or personal
injury that might result from my non-compliance with the mandate of the NCAA, St. Joseph’s Candler
Sports Medicine and Armstrong Atlantic State University Athletics Department
Student-Athletes Need to:
1. Contact their parents/guardian and your pediatrician (at birth) and get documentation showing
what your sickle cell trait status is.
 Infants born after 1984 were tested for the sickle cell trait and therefore the documentation
should be available from your family pediatrician.
OR
2. Schedule an appointment with Health Services at the Student Affairs Annex for a Sickle Cell trait
blood test. All appointments must be made before 2:30pm. There is a charge for this test.
OR
3. Sign a waiver releasing the State of Georgia, the University, its officers, employees and agents
from any and all costs, liability, expense claims, demands or causes of action on account of any
loss or personal injury that might result from my non-compliance with the mandate of the NCAA,
St. Joseph’s Candler Sports Medicine and Armstrong Atlantic State University Athletics
Department.
 The signing of the waiver is not recommended. It is preferred that all studentathletes know their status to help ensure their health and wellbeing during
participation in athletics. We are advising all student-athletes to consult with their
parent or guardian before signing the waiver.
If you are signing the Waiver only fill out Page 14
13
Sickle Cell Testing Waiver Form
About Sickle Cell Trait



Sickle cell trait is an inherited condition of the oxygen-carrying protein, hemoglobin, in the red blood cells.
Sickle cell trait is a common condition (> three million Americans)
Although 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 races and ancestry may test positive for
sickle cell trait.
Sickle cell trait is usually benign, but during intense, sustained exercise, hypoxia (lack of oxygen) in the muscles may
cause sickling of red blood cells (red blood cells changing from a normal disc shape to a crescent or “sickle” shape),
which can accumulate in the bloodstream and “log jam” blood vessels, leading to collapse from the rapid breakdown
of muscles starved of blood.
Sickle Cell Trait Testing


The NCAA, St. Joseph’s Candler Sports Medicine and Armstrong Atlantic State University Athletics Department
mandates that all NCAA student-athletes have knowledge of their sickle cell trait status, show proof of a prior test or
sign a waiver before the student-athlete participates in any intercollegiate athletics event, including strength and
conditioning sessions, practices, competitions, etc.
The Chatham County Health Department offers sickle cell trait screening in the form of a blood test to all students for
a fee. Results will be reported to Armstrong Atlantic State Athletics Department and/or a member of the Armstrong
Atlantic State Sports Medicine Department.
Athletes should read through Armstrong Atlantic State University Sickle Cell Position Statement.
SICKLE CELL TRAIT TESTING WAIVER
I, _______________________________, understand and acknowledge that the NCAA, SJCHS and AASU Athletics mandates that all
students athletes have knowledge of their sickle cell trait status. Additionally, I have read and fully understand the
aforementioned facts about sickle cell trait and sickle cell trait testing.
Recognizing that my true physical condition is dependent upon an accurate medical history and a full disclosure of any
symptoms, complaints, prior injuries, ailments, and/or disabilities experienced, I hereby affirm that I have fully
disclosed in writing any prior medical history and/or knowledge of sickle cell trait status to SJCHS and AASU Sports
Medicine personnel.
I do not wish to undergo sickle cell trait testing and I voluntarily agree to release, discharge, indemnify and hold
harmless the State of Georgia, the University, St. Joseph’s Candler Hospital its officers, employees and agents from any
and all costs, liabilities, expenses, claims, demands, or causes of action on account of any loss or personal injury that
might result from my non-compliance with the mandate of the NCAA, SJCHS and Armstrong Atlantic State University
Athletics Department
I have read and signed this document with full knowledge of its significance. I further state that I am at least 18 years of
age and competent to sign this waiver.
_________________________________________________
Student-Athlete Signature
___________________
Date
_________________________________________________
___________________
Parent/Guardian Signature (if under 18 years of age) UID #
__________________________________________________
Parent/Guardian Print Name
___________________
Date
__________________________________________________
Witness
___________________
Date
14
Sickle Cell Disclosure Form
I, ______________________________________ affirm that I have been informed by my family physician as to my
Sickle Cell Trait Status, and/or have undergone the sickle cell trait screening, in the form of a blood test.
1. Sickle Cell Trait Positive
Initial ___________
2. Sickle Cell Trait Negative
Initial ___________
About Sickle Cell Trait Sickle cell trait is an inherited condition of the oxygen-carrying protein, hemoglobin, in the red
blood cells.
 Although 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 races
and ancestry may test positive for sickle cell trait.
 Sickle cell trait is usually benign, but during intense, sustained exercise, hypoxia (lack of oxygen)
in the muscles may cause sickling of red blood cells (red blood cells changing from a normal disc
shape to a crescent or “sickle” shape), which can accumulate in the bloodstream and “logjam”
blood vessels, leading to collapse from the rapid breakdown of muscles starved of blood.
 Likely sickling settings include timed runs, all out exertion of any type for 2 – 3 continuous
minutes without a rest period, intense drills and other spurts of exercise after prolonged
conditioning exercises, and other extreme conditioning sessions.
 Common signs and symptoms of a sickle cell emergency include, but are not limited to: increased
pain and weakness in the working muscles (especially the legs, buttocks, and/or low back);
cramping type pain of muscles; soft, flaccid muscle tone; and/or immediate symptoms with no
early warning signs.
I, the undersigned, do hereby affirm that I have been informed of my sickle cell trait status by my
family physician and/or one of the clinicians at Armstrong Atlantic State University Sports Medicine
Department. If my sickle cell trait status is positive I understand that I am required to undergo
educational sessions around the topic of sickle cell and understand that specific precautions that
need to be undertaken due to the serious nature of the condition. The educational sessions will be
administered by the Armstrong Atlantic State University Sports Medicine Department. I also affirm
that I have read through Armstrong Atlantic State University Athletics Sickle Cell Position
Statement.
______________________________________________________
___________________
______________________________________________________
___________________
___________________________________________________________
Examining Physician Print Name
_____________________
Date
____________________________________________________________
Athletic Trainer Signature
_____________________
Date
Student-Athlete Signature (If under 18, include parent/guardian signature)
Examining Physician Signature
Date
Date
15
Concussion and Injury Reporting Agreement Form
NCAA regulations require all varsity student-athletes to be aware of what a concussion is, as
well as signs and symptoms of concussion. Please read the below information and sign and date
the bottom of the form to be in compliance with NCAA regulations.
What is a concussion?
A concussion is a brain injury that may be caused by a blow to the head, face, neck, or
elsewhere on the body with an “impulsive” force transmitted to the head. Concussions can also
result from hitting a hard surface such as the ground, ice or floor, from players colliding with
each other or being hit by a piece of equipment such as a bat, lacrosse stick, or field hockey
ball.
Signs and Symptoms of a concussion:
Headache, nausea, vomiting, balance problems or dizziness, double or blurry vision, sensitivity
to light, sensitivity to noise, feeling sluggish, hazy, foggy, or groggy, concentration or memory
problems, confusion.
I, (please print)_______________________________________ do hereby agree to accept the
responsibility for reporting all injuries and illness to the Armstrong Atlantic State University Sports
Medicine Staff, including signs and symptoms of concussion.
Signature of Athlete________________________________________ Date_______________
Sport(s)______________________________________________________
Request parent/guardian signature if student-athlete is under 18 years old
Parent/Guardian Signature__________________________________ Date________________
16
The Armstrong Atlantic State Athletic Department
Consent to Drug Test and Authorization for
Release of Information
I hereby acknowledge receipt of a copy of the Armstrong Atlantic State Department reasonable suspicion
and voluntary drug testing program for student-athletes. I further acknowledge that I have read this policy and fully
understand its provisions.
It is my understanding that signing this consent form and returning it is a prerequisite to becoming a
member of the intercollegiate team at Armstrong Atlantic State. I further understand that I may refuse to sign this
consent form, but as a consequence, I must forego participation in intercollegiate sports at the University.
I am aware that I am expected to abide by team rules, that such rules are subject to change, and that I may
be dismissed from the team and/or deprived of my grant-in-aid or scholarship for failure to abide by such rules. I
acknowledge my understanding that the use or abuse of drugs not prescribed by a physician for a specific medical
condition is a violation of team rules.
I hereby consent to have samples of my urine collected and tested for the presence of certain drugs or
substances in accordance with the provision of the Armstrong Atlantic State Drug Testing Program.
I further authorize the Team Physician at Armstrong Atlantic State to make a confidential release to the
head coach of any intercollegiate sports in which I am a team member, the Athletic Director at Armstrong Atlantic
State and, if a minor, my parent(s) or legal guardian(s), all information and records, including test results you may
have relating to the screening or testing of my urine sample(s) in accordance with the provision of the Armstrong
Atlantic State Drug Testing Program which is applicable to all intercollegiate athletes at Armstrong Atlantic State.
To the extent set forth in this document, I waive any privilege I may have in connection with such
information. I further agree that, in the event the results of my drug screening test are positive, I will follow the
procedures stated in the section of the policy entitled “Positive Test Results” Armstrong Atlantic State, its Board of
Trustees, its officers, employees and agents are hereby released from legal responsibility or liability for the release
of such information and records as authorized by this form.
Parent’s Signature ____________________
(if student-athlete is under 18)
Student-Athletes Signature _____________________________ Print Full Name_________ __________________
Date ___________
____________________________________
(907)Number –Student ID number
____________________________________
Intercollegiate Sport
17
The Undersign (Athlete, Parent/Guardian) herewith,
A) Understands that any medical expense incurred due to the above pre-existing conditions and not
directly attributed to athletic participation at Armstrong Atlantic State 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 examination.
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 trainers and/or physician orders, until he/she is discharged or given permission by
staff certified athletic trainer to restart participation despite continuation of treatment.
E) Understands that having passed the pre-participation physical examination 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 said time of evaluation.
F) Understands that the athlete will not be allowed to participate in any intercollegiate athletics until
all forms are complete.
G) Certifies that the above answers are correct and true.
______________________________________________________
Athlete’s Printed Name
_____________________________
Date
______________________________________________________
Athlete’s Signature
_____________________________________________________
Parent/Guardian Printed Name
(if Athlete under age of 18)
_____________________________
Date
_____________________________________________________
Parent/Guardian Signature
(if Athlete under age of 18)
*Upon the completion of the History Form, it is to be reviewed and signed by a Staff Certified Athletic Trainer.
____________________________________________________
Staff Certified Athletic Trainer Signature
18
_____________________________
Date