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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