usciences athletics · web viewdan wager, ms, atc/l, cscschristi lee, ms, atc/l tyler feldman, ms,...
TRANSCRIPT
NAME:____________________________
PLEASE RETURN THE FOLLOWING FORMS ENCLOSED IN AN ENVELOPE:
1. ACKNOWLEDGMENT OF INSURANCE REQUIREMENTS FORM (signed)
2. INSURANCE INFORMATION (signed)
3. PHOTO-COPY (front/back) OF CURRENT INSURANCE CARD (please read enclosed information on institutional insurance in case you need it)
4. EMERGENCY CONTACT FORM
5. STUDENT-ATHLETE AUTHORIZATION/CONSENT FORM (singed or unsigned)
6. CONCUSSION IMPACT CONSENT FORM (signed)
7. CONCUSSIONWISE TEST CERTIFICATE (FIRST-YEAR ATHLETES ONLY)
8. SICKLE CELL TESTING FORM (signed)
9. MEDICAL CONSENT FORM (signed)
10. MEDICAL HISTORY QUESTIONNAIRE (completed)
11. PRE-PARTICIPATION MEDICAL EXAMINATION FORM (to be performed by a physician AFTER June 1, 2018; any physical done before June 1, 2018 WILL NOT be accepted) Please be sure the physician includes documentation on dosage, usage and why any medication is prescribed. Student-Athletes with Attention Deficit Hyperactivity Disorder (ADHD) will need their physician to document accordingly. Please include a letter from physician for any medications you are currently taking!
WE NEED ALL FORMS ON FILE BEFORE A STUDENT-ATHLETE CAN PRACTICE AND/OR PLAY. FORMS MUST BE TURNED IN BY JULY 1, 2018.
THANK YOU!
Dan Wager, MS, ATC/L, CSCS Christi Lee, MS, ATC/L Tyler Feldman, MS, ATC/LAthletic Trainer/Strength & Conditioning Coach Athletic Trainer Asst. Athletic Trainer
UNIVERSITY OF THE SCIENCESATTN: ATHLETICS – SPORTS MEDICINE
600 S. 43RD STREETPHILADELPHIA, PA 19104
215-596-7430
Dear Parent/Guardian/Student-Athlete,
I hope all is well! I would like to welcome you (or welcome back) to University of the Sciences Athletics. In this packet you will find all of the necessary medical forms required prior to participation in athletics. Please keep in mind that all forms need to be turned in by July 1, 2018 in order to participate in University of the Sciences Athletic games, practices, and competitions. In addition to your Pre-Participation Medical Exam Form, you will also need to have your primary care physician review your Medical History Form.
The NCAA now requires that all student-athletes have on file the date of their Sickle Cell Trait screening, including proper documentation, or denial of the screening. You will find information on Sickle Cell Trait as well as the wavier in this packet. Please make sure you review the material and sign all necessary paperwork. If you have a copy of your test results you can attach it to the wavier and send it in with the packet as a whole.
Due to the increased requests from health care facilities, please submit a photocopy, both front and back, of all appropriate insurance cards for your student-athlete. It is your responsibility to keep us up to date with current insurance cards if your insurance changes during the school year. Please attach a copy, both front and back, of your insurance card(s) to the Acknowledgement of Insurance Requirements Form (Form #1) and send it in with your packet as a whole. Remember you must have current private insurance in order to participate in varsity athletics at the University of the Sciences.
The same information may be requested on a few different forms. This is necessary since these forms are used to provide valuable information for different situations. Please fill out all requested information on all forms, regardless if the information has already been addressed in a prior form.
** Please note that the forms the Athletic Training Dept. are requesting are not the same as the forms requested by the Student Health Center. Both sets must be filled out and sent back to the proper office. The forms being requested in this letter are to be returned to the Athletic Training Department and do not require a physician’s signature EXCEPT for the Athletics Participation Physical Evaluation and ADHD or Clearance (if applicable) forms.
** Please type or use blue or black ink for all forms**
Over the SUMMER please notify us of any injury or illness prior or present that effects your ability to play or condition for your varsity sport(s). A PPE CLEARNCE FORM (found online) from an attending physician will be needed for clearance of any such injury/illness PRIOR to being able to participate.
It is essential that all necessary forms be correctly completed on time, and sent in together, in order to participate in USP Athletics. Thank you for your cooperation and time in taking one more step in making this a successful year.
FORM #1 (needs parent signature)
ACKNOWLEDGMENT OF INSURANCE REQUIREMNETS
I, ___________________________________, as parent, guardian, or legal representative attest that (parent/guardian name; please print)
_____________________________________ has insurance coverage under a current, in force (student-athlete’s name; please print)
insurance policy for injuries that occur while he/she is participating in intercollegiate athletics.
If there is a material change in coverage or expiration of coverage, I agree to notify the University of the Sciences of this development and update the insurance information I have on file with USciences.
I understand and agree that USciences assumes no responsibility whatsoever for the payment, of or authorization to pay, medical expenses resulting in injuries that occur while participating in intercollegiate athletics at USciences if the student-athlete does not have current medical insurance coverage. I also understand that once the current medical insurance coverage payments have been exhausted, that the USciences institutional policy will pay additional bills.
Any OUT OF STATE OR INTERNATIONAL STUDENT must check with their insurance company to make sure they are not considered “out of network” while at University of the Sciences. If the athlete’s insurance is considered “out of network” then they could be limited to what medical care they can receive. In the event of an injury the athlete will need to have full coverage. If their personal insurance does not allow them to use our team physician through Penn Medicine, they will be asked to consider adding a guest membership to be used during the school year. Check with your insurance company to see what kind of Guest Membership or “Away From Home Care” options they have. Most insurances allow you to add this to your existing policy with no added fees. Please note, when an athlete is restricted with their insurance it could limit them to getting the best care possible and could significantly delay their return to play.
___________________________________________ __________________ Parent/Guardian Signature Date
**YOU MUST INCLUDE A COPY (FRONT & BACK) OF YOUR CURRENT INSURANCE CARD**
FORM #2 (needs parent signature)
UNIVERSITY OF THE SCIENCES 2018-2019 INSURANCE INFORMATION FORM
POLICY HOLDER NAME: ______________________________________________________
SUBSCRIBER DOB: ___________________________________________________________
RELATIONSHIP TO STUDENT-ATHLETE: ________________________________________
SUBSCRIBER ADDRESS: _______________________________________________________
INSURANCE COMPANY NAME: ________________________________________________
INSURANCE TYPE (HMO, PPO, OTHER): ________________________________________
INSURANCE COMPANY ADDRESS: _____________________________________________
INSURANCE PHONE #: ________________________________________________________
GROUP/PLAN #: ______________________________________________________________
POLICY ID #: _________________________________________________________________
DOES THE POLICY COVER ATHLETIC-RELATED INJURIES: Yes:_______ No:________
PRIMARY CARE PHYSICIAN: __________________________________________________
OFFICE PHONE #: _____________________________________________________________
I have read and agree to comply with the provisions of the Acknowledgement of Insurance Requirements. I understand that I am required to inform the University of the Sciences Athletics Department about any change in insurance policy. Furthermore, I understand that University of the Sciences cannot pay any insurance claims if student/athlete is not covered by health insurance.
______________________________________ ______________________________________PARENT/GUARDIAN SIGNATURE & DATE STUDENT-ATHLETE SIGNATURE & DATE
FORM #4
UNIVERSITY OF THE SCIENCES2018-2019 EMERGENCY CONTACT INFORMATION
ATHLETE’S NAME: __________________________________ DOB: ______________ GENDER: _________
SPORT: _______________________________________ STUDENT ID #: ___________________________
HOME ADDRESS: _______________________________ HOME PHONE #: __________________________
_______________________________ STUDENT CELL #: _________________________
_______________________________ SCHOOL EMAIL: __________________________
SCHOOL ADDRESS: _____________________________________
_____________________________________
_____________________________________
CONTACT 1:
PARENT/GUARDIAN NAME: _________________________________________________________________
RELATIONSHIP TO STUDENT-ATHLETE: _____________________________________________________
ADDRESS: _______________________________ HOME PHONE #: ________________________________
_______________________________ CELL PHONE #: _________________________________
_______________________________ WORK PHONE #: ________________________________
EMAIL: ____________________________________________________________________________________
CONTACT 2:
PARENT/GUARDIAN NAME: _________________________________________________________________
RELATIONSHIP TO STUDENT-ATHLETE: _____________________________________________________
ADDRESS: _______________________________ HOME PHONE #: ________________________________
_______________________________ CELL PHONE #: _________________________________
_______________________________ WORK PHONE #: ________________________________
EMAIL: ____________________________________________________________________________________
FORM #5
Student-Athlete Authorization/Consent for Disclosure of Protected Health Information
for NCAA-Related Research Purposes
I, ____________________________________ hereby authorize ________University of the Sciences_________ Name of Student-Athlete Name of my Institution
and its physicians, athletic trainers and health care personnel to disclose my protected health information including, without limitation, any information regarding any injury, illness, treatment or participation related to or affecting my training for and participation in intercollegiate athletics to the National Collegiate Athletic Association (NCAA), and its designated employees, agents and/or contractors. I further authorize the NCAA to disclose, and/or use, such information as provided herein.
I understand that my participation and protected health information may be disclosed to, and/or used by, the NCAA, and authorized third parties to receive such information for the purpose of using injury, relevant illness and participation information collected from multiple student-athletes and institutions in a manner that does not identify myself or my school. The information is provided to NCAA committees, athletics conferences and individual schools, and NCAA-approved researchers to evaluate the effectiveness of health and safety rules and policy, and to study other sports medicine questions. Selected de-identified summary (aggregate) data also are made accessible to the general public as a service to further the general understanding of athletic injury patterns and help develop education on student-athlete health topics.
I am making this authorization/consent voluntarily to release my health information otherwise protected by federal regulations under either the Health Information Portability and Accountability Act (HIPAA) or the Family Educational Rights and Privacy Act of 1974 (the Buckley Amendment). The NCAA and institution are not requiring this authorization/consent to be signed.
I understand that while HIPAA regulations may not apply to NCAA use or disclosure of my injury/illness information, the NCAA is committed to protecting my privacy. I understand that my data will be stored securely within industry standards.
This authorization/consent for transfer of protected health information expires 545 days from the date of my signature below, but I have the right to revoke it in writing at any time by sending written notification to the director of athletics at my institution. I understand that a revocation takes effect on its request date and does not affect any action taken prior to that date.
___________________________________________ _______________________________________________Printed name of student-athlete Signature Date
Dear Parent / Guardian /Athlete,
University of the Sciences is currently implementing an innovative program for our student-athletes. This program will assist our team physicians & athletic trainers in evaluating and treating head injuries (e.g., concussion). In order to better manage concussions sustained by our student-athletes, we have acquired a software tool called ImPACT (Immediate Post Concussion Assessment and Cognitive Testing). ImPACT is a computerized exam utilized in many professional, collegiate, and high school sports programs across the country to successfully diagnose and manage concussions. If an athlete is believed to have suffered a head injury during competition, ImPACT is used to help determine the severity of the head injury and when the injury has fully healed.
The computerized exam is given to athletes before beginning contact sport practice or competition. This non-invasive test is set up in “video-game” type format and takes about 15-20 minutes to complete. It is simple, and actually many athletes enjoy the challenge of taking the test. Essentially, the ImPACT test is a preseason physical of the brain. It tracks information such as memory, reaction time, speed, and concentration. It, however, is not an IQ test.
If a concussion is suspected, the athlete will be required to re-take the test. Both the preseason and post-injury test data is given to our team physician or concussion specialist, to help evaluate the injury. The information gathered can also be shared with your family doctor. The test data will enable these health professionals to determine when return-to-play is appropriate and safe for the injured athlete.
I wish to stress that the ImPACT testing procedures are non-invasive, and they pose no risks to your student-athlete. We are excited to implement this program given that it provides us the best available information for managing concussions and preventing potential brain damage that can occur with multiple concussions. The University of the Sciences administration, coaching, and athletic training staffs are trying to keep your child’s health and safety at the forefront of the student athletic experience. Please return the attached page with the appropriate signatures. If you have further questions regarding this program please feel free to contact me at 215-596-7430.
Sincerely,Athletic Training StaffUniversity of the Sciences600 S. 43rd StreetPhiladelphia, PA 19104
FORM #6
ImPACT CONSENT FORM
For use of the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)
I have read the attached information. I understand its contents. I have been given an opportunity to ask questions and all questions have been answered to my satisfaction. I agree to participate in the ImPACT Concussion Management Program.
Printed Name of Athlete: _________________________________________
Sport: _________________________________________________________
_____________________________________ __________________ Signature of Athlete Date
_____________________________________ ___________________ Signature of Parent/Guardian Date (if not 18 years or older)
FORM #7
CONCUSSION WISE PAPERWORK (FIRST-YEAR ATHLETES ONLY)
In recent years, there has been more research on concussions and in effort to stay up-to-date with current concussion trends/treatments/education we are requiring all athletes to watch a video on concussions, then take the test at the end of the video. All athletes must turn in confirmation that they have successfully completed the test in order to participate in their respective sport. The website and steps will be listed at the bottom of this letter. We greatly appreciate your understanding. We are anticipating an awesome year of athletics and look forward to seeing you at some events!
Please follow the instructions below to access the ConcussionWise video and quiz.- Go to www.sportsafetyinternational.org- Click on the “Available Courses Tab”- Scroll down to the “ConcussionWise” subtab and click on “ConcussionWise Education for Athletes”- The video will appear, you will need to hit “play” and watch the ENTIRE video, as that is the only way to access the test- At the end of the video, you will be prompted to “click” the screen for the post-test- Once you finish the test, print the certificate (sample certificate below) and turn it in to the
Athletic Training Staff**SAMPLE CERTIFICATE BELOW**
Sincerely,Athletic Training StaffUniversity of the Sciences-Sports Medicine600 S. 43rd Street, Philadelphia, PA 19104
SICKLE CELL TRAIT TESTING
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 University of the Sciences of liability if they decline to be tested. In accordance with this legislation, University of the Sciences Athletic Training Staff 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 Pennsylvania, the University of the Sciences, 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 non-compliance with the mandate of the NCAA and the University of the Sciences Athletic Training Staff.
The NCAA mandates that all NCAA student-athletes have knowledge of their sickle cell trait status before the student-athlete participates in any intercollegiate athletics event, including strength and conditioning sessions, practices, competitions, etc…
Sickle cell trait testing in the form of a blood test can be done by the student-athlete’s personal primary care physician. Testing will be billed only to the athlete’s primary insurance.
If you have already been tested for sickle cell trait, please provide a copy of the written results to the Sports Medicine Team. Infants born after 1984 might have been tested for sickle cell trait and therefore the documentation could be available from your family pediatrician. Contact your pediatrician (at birth) and get documentation, if available, showing what your Sickle Cell Trait status is.
If you have not been previously tested and do not agree to test, please review the waiver below.
FORM #8
SPORT: _______________________
UNIVERSITY OF THE SCIENCES SICKLE CELL TESTING OPTIONS
The NCAA requires all incoming and new student-athletes to be tested for sickle cell trait or show proof of a prior sickle cell trait test. Alternatively, student-athletes may decline a test and sign a written release.
Please do one of the following (check one):□ Provide documented evidence of a previous sickle cell solubility test & attach the results to this form.□ Decline the test
**IF FIRST BOX IS CHECKED, PLEASE PROVIDE DOCUMENTATION OF TEST & ATTACH RESULTS**
If sickle cell solubility test is DECLINED, please read and complete the following:
I acknowledge that I have read and understand the following:Screening for Sickle Cell Trait is required for all newborns in the United States. If you do not have documentation that your son or daughter has had this screening, please ask your physician to perform another test. If your child declines to have this test performed or if you decline to have your minor child tested, then please sign the waiver we have provided prior to your child’s arrival on campus to participate in athletics. Please understand that the University of the Sciences is not responsible for any expense incurred in obtaining this documentation.
After reading such information, I hereby decline to obtain the sickle cell test. In declining the test, I agree to waive and release any and all claims against the University of the Sciences and its employees for personal injury, including death, arising out of my failure to obtain the sickle cell test. I recognize that this release means I am giving up, among other things, rights to sue the University of the Sciences and its employees for injuries, damages or losses I may incur. I also understand that this release binds my heirs, executors, administrators and assigns, as well as myself.
Student’s Name: _________________________________________________________
Student’s Signature: _______________________________________________________ Date: ___________________
Parent’s Name (if student is under 18): ________________________________________
Parent’s Signature (if student is under 18): _____________________________________ Date: __________________
FORM #9
UNIVERSITY OF THE SCIENCES MEDICAL CONSENT FORM
The undersigned, herewith:A. Understands that he/she must refrain from practice or play during medical treatment until he/she is
discharged from treatment or given a written permit by the attending physician to resume participation.
B. Fully realizes that University of the Sciences cannot be held responsible for any previous medical condition(s) that he/she might have or any medical expense incurred due to any identified pre-existing medical condition and/or not directly attributable to any athletic participation at the University of the Sciences.
C. Understands that the athletic medical insurance at University of the Sciences is secondary coverage, which will cover the remaining balance on an athletic related injury only.
D. Understand the chance of sustaining a catastrophic sports injury is extremely remote, yet, understand that serious injuries can and do occur to anyone.
E. Participation in your sport could result in death, serious neck and spinal injuries which may result in complete or partial paralysis, brain damage, serious injury to all internal organs, serious injury to all bones, joints, ligaments, muscles, tendons, and other aspects of the musculoskeletal system, and serious injury or impairment to other aspects of your body, general health and well-being.
F. Grant the athletic trainers, team physicians, therapists, technicians, and consultants of the University of the Sciences to render me any emergency, medical, surgical, or other care that might be deemed necessary to insure proper care of any injury/illness, and to maintain my health and well-being. In the absence of the team or authorized physician, I grant permission to a qualified physician to furnish emergency care using the guidelines above. Also, when necessary for executing such care, permission for hospitalization at an accredited hospital is granted.
______________________________________________ __________________Student Athlete Signature (Parent/Guardian under 18) Date
