Dear 2014-2015 Incoming Student-Athletes of Macalester College,
On behalf of the Athletic Training Staff we would like to take this opportunity to welcome you to Macalester College and the Athletics Department. We are looking forward to meeting you this fall as you join your team and participate as a Macalester Scot. As you are preparing for your first year at Macalester, we would like to give you a quick list of things that we need you to do in order to be eligible to participate in the athletics program at Macalester College.
1. Complete the following medical information packet: A full health physical must be performed by your family physician. This physical needs to be done within 6 months of your first practice with your team at Macalester College. Pages 8 and 9 of this form are what you take to your Dr to complete!
Please mail the completed packet to us by July 15th for Fall sport athletes and August 1st for all other teams, to: Paula Natvig, Athletic Trainer 1600 Grand Ave., St. Paul, MN 55105
2. Complete an online medical history: This can be found at: www.swol123.net. This can only be done after you have received your Macalester email address. To begin, enter your email address and your password. Your default password will be the first letter of your first name and your entire last name. You can change this once you are logged in. Click on the “My Info” tab and complete the general, address, emergency contact and insurance tabs. Then click on “Med History” tab and complete the medical history questionnaire.
3. Take the Impact Concussion Test Once you arrive on campus, you will meet with the Athletic Training staff and have an orthopaedic exam and take the Impact Concussion Test. Head Coaches will schedule a time when your team will participate in this testing.
As you are completing your paperwork, if you have any questions or concerns, please do not hesitate to contact us at the email or phone numbers listed below.
If you have any questions specific to medical insurance, please contact Sue Rothenbacher, Macalester College Insurance Coordinator, at [email protected].
I hope you have a wonderful summer and we are looking forward to meeting you in the fall.
Sincerely,
Paula Natvig, A.T.,C. Matt Seamon, A.T.,C Head Athletic Trainer Assistant Athletic Trainer Macalester College Macalester College 1600 Grand Ave. [email protected] St. Paul, MN 55105 651-696-6404 office phone [email protected] 651-696-6162 office phone 2 STUDENT INTERCOLLEGIATE ATHLETES (Domestic) – May 2014 Macalester Athletics Macalester College – 1600 Grand Avenue – St. Paul, MN 55105 Athletic Training: 651-696-6162 Fax: 651-696-6839 Head Athletic Trainer: [email protected] Assistant Trainer: [email protected]
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I. REQUIREMENTS FOR INTERCOLLEGIATE ATHLETES: In addition to the Immunization Record, TB Screening/Testing, and Privacy Statement, you must complete & return the health history, physical, and athletic insurance forms by July 15, 2014. Completion of these forms is required in order to participate in intercollegiate athletics. We strongly recommend that the physical and approval be completed at home because it could cost approximately $250 or more to have the physical (must be within the last six months) and necessary immunizations in the St. Paul community – these services are offered by Macalester College, but fall sport athletes participation may be delayed if it is completed here. Paula Natvig, Head Athletic Trainer, coordinates athletic medicine for Macalester College
II. HEALTH INSURANCE : Macalester College requires ALL students show proof of comprehensive personal health insurance coverage. Health insurance is NOT required to use the health & wellness services offered at the college but is needed for any care or service off-campus and to participate in intercollegiate athletics. a. Athletes are asked to provide an actual copy of their insurance card for the records of the athletic department . NOTE: This is separate from enrolling in/waiving out of the college-offered health insurance policy – you still need to go online and do that step (See next paragraph). b. All students are charged for the health insurance on the first bill – every year. Macalester College requires that all students each year either “enroll” or “waive out” of the insurance plan offered by the college. If you waive out, the charge is removed on the next bill. If you enroll, the charge remains. If you do not do either one of these, you will automatically be enrolled in this plan and the charge remains on your bill. See the website on Health Insurance http://www.macalester.edu/health/insurance.html .
The “enroll/waive out” process begins approximately July 1, 2013 and the deadline to complete the process is September 4, 2012. If you have questions, please email them to [email protected] . Note that the office is only staffed part-time during June and July. We will get back to you as soon as possible.
Sue Rothenbacher, Executive Assistant, assists students and their families with the Macalester insurance plan and works directly with students who have questions regarding insurance coverage, submitting for reimbursement, etc. Questions concerning the athletics-required insurance information should be directed to Paula Natvig, Athletics.
III. ATHLETICS REQUIREMENTS CHECKLIST ( To be completed and mailed to above address before July 15, 2014):
1. Complete Information form and Medical History (pages 3-7)
2. Take the medical history and pages 8- 9 of this form to your physician and have your medical physical completed. Be sure all portions are completed and signed. NCAA rules requires that this physical is performed 6 months or less prior to your first team practice.
3. Complete Insurance Requirement (page 10) and attach copies of insurance card
4. Complete the HIPPA agreement (page 11) Sickle Cell trait form (page 12) and attach test results and Consent for treatment form (page 13). Send entire packet to Paula Natvig at 1600 Grand Ave St. Paul, MN 55105
5. Go to www.swol123.net to complete our online medical information. Please use your Macalester College email address to sign in as your login and your password is the first letter or you first name and your entire last name. Contact Paula @ [email protected] if you have problems with this! Complete the following sections: General, Address, Emergency, Insurance and under “My Info” fill out the medical history questionnaire.
3 Macalester Sports Medicine Athlete Information Form 2014/2015
Athlete Information Name of Athlete:______Sport(s): ______Year in School: fr so jr sr Date of Birth: ______Social Security # Local Address ______Cell Phone:
Parent/Guardian Information Mother/Guardian Name: ______Day Phone: ______Evening Phone: ______Address: ______City/State/Zip: ______Email: ______
Father/Guardian Name: ______Day Phone: ______Evening Phone: ______Address: ______City/State/Zip: ______Email: ______
Emergency Information (different from above ex. Grandparent, sibling or family friend) Person(s) to be contacted in case of emergency: ______Relationship: ______Day Phone: ______Evening Phone: ______Email: ______Address: ______City/State/Zip: ______
4 MACALESTER COLLEGE Athletics Department Form must be completed 1600 Grand Avenue, Saint Paul, Minnesota 55105 and returned by mail, fax Athletics : Phone : 651.696. 6162 – FAX : 651.696.6839 Return completed forms to: Paula Natvig,or Head e-mail Athletic before Trainer 1600 Grand Ave., St. Paul, MN 55105 July 15 FAX : 651.696.6839 HEALTH HISTORY RECORD 2014-15 DOMESTIC STUDENT / ATHLETE
I. STUDENT’S REPORT OF MEDICAL HISTORY… (PLEASE PRINT) ======______Last Name First Name Middle Gender Date of Birth ______Home Address (Number and Street) City or Town State Country Zip ______Next of Kin: Name Relationship Primary Phone Number Secondary Phone Number ______Name of person to call in case of emergency : Relationship Primary Phone Number Secondary Phone Number
______Student’s Email Address Student’s Cell Phone Number
______Primary Health Care Provider (print name) Primary Health Care Provider Office Phone Number
Family History Current Age/Occupation Health Status: Father’s Name Mother’s Name Siblings Names
Are you adopted? □ Yes □ No With whom do you live? □ Parents □ Mother □ Father □ Spouse □ Self □ Other
PLEASE CIRCLE YES and explain; if you have had any of the following diseases or conditions or CIRCLE NO if not GENERAL Has a doctor ever denied or restricted your participation in sports for any reason or told you to give up sports? Yes No
Do you have ongoing medical conditions (i.e. diabetes, asthma)? Yes No
Have you ever spent the night in a hospital? Yes No
Have you ever had surgery? Yes No
Have you ever had a hernia? Yes No
Were you born without or are you missing a kidney, an eye, a testicle, or any other organ? Yes No
Have you ever been told you have protein/sugar in your urine? Yes No
When exercising in the heat, do you have severe muscle cramps or become ill? Yes No
Do you have any concerns that you would like to discuss with a doctor? Yes No
Yes No
ALLERGIES Do you have allergies to any medications? Yes No
If yes, please list Other allergies: Yes No
If yes, please list CARDIOVASCULAR Have you ever passed out or nearly passed out DURING exercise? Yes No
Have you ever passed out or nearly passed out AFTER exercise? Yes No
Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise? Yes No
Does your heart race or skip beats during exercise? Yes No
Has a doctor ever told you that you have? (circle all that apply) High Blood Pressure High Cholesterol A Heart Infection or Murmur Rheumatic Fever Has a doctor ever ordered a test for your heart? (i.e. ECG, echocardiogram, stress test) Yes No
Has anyone in your family died suddenly and unexpectedly for no apparent reason? Yes No
Does anyone in your family have a heart problem? Yes No
Has any family member or relative died of heart problems or of sudden death before age 50? Yes No
Does anyone in your family have Marfan syndrome? Yes No
ORTHO Have you ever had an injury, like a sprain, muscle or ligament tear or tendonitis that caused you to miss a practice or a game? Yes No
Have you had any broken or fractured bones, or dislocated joints? Yes No
Have you had a bone/joint injury that required x-rays, MRI, CT, surgery, injections, rehabilitation, physical therapy, a brace, a cast or crutches? Yes No
If yes, circle below: Head Neck Shoulder Chest Upper Arm Elbow Forearm Hand/Fingers Upper Back Lower Back Hip Thigh Knee Calf/Shin Ankle Foot/Toes Have you ever had a stress fracture or stress reaction? Yes No
Have you been told that you have or have you had an x-ray for atlantoaxial (neck) instability? Yes No
Do you regularly use a brace or assistive device? Yes No
RESPIRATORY Have you ever had bronchitis? Yes No
Has a doctor every told you that you have asthma or allergies? Yes No
Do you cough, wheeze, chest tightness, or have difficulty breathing during or after exercise? Yes No
Is there anyone in your family who has asthma? Yes No
Have you ever used an inhaler or taken asthma medicine? Yes No
Do you develop a rash or hives when you exercise? Yes No
Do you get tired more quickly than your friends do during exercise? Yes No
INFECTIOUS Have you recently had a Tuberculosis Skin Test? Yes No
If you answered Yes above, the results were: Negative Positive Have you had infectious mononucleosis (mono) within the last month? Yes No
Have you had chicken pox? Yes No
Have you had German measles? Yes No
Have you had measles? Yes No
Have you had mumps? Yes No
SKIN Do you have any rashes, pressure sores, or other skin problems? Yes No
Have you had a herpes skin infection? Yes No
6 NEUROLOGIC Have you ever had a head injury; concussion; been knocked out or head your “bell ring”? Yes No
Have you been hit in the head and been confused or lost your memory? Yes No
Have you ever had a seizure? Yes No
Do you have headaches with exercise? Yes No
Have you ever had a “stinger or burner” Yes No
Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling? Yes No
Have you ever been unable to move your arms or legs after being hit or falling? Yes No
BLOOD Have you ever been told you are anemic? Yes No
Has a doctor told you that you or someone in your family has sickle cell trait or sickle cell disease? Yes No
Have you been tested for sickle cell trait? Yes No
If you answered Yes above, the results were: Negative Positive What was the date of your sickle cell test? ____/____/____ Any other blood disorder? Yes No
VISION Have you had any problems with your eyes or vision? Yes No
Do you wear glasses or contact lenses? Yes No
Do you wear protective eyewear, such as goggles or a face shield? Yes No
NUTRITION Are you taking any vitamins or supplements? Yes No
Are you happy with your weight? Yes No
Are you trying to gain or lose weight? Yes No
What has been your highest & lowest weight in the past 12 months? High Low Has anyone recommended you change your weight or eating habits? Yes No
Do you limit or carefully control what you eat? Yes No
Have you ever been diagnosed with an eating disorder? Yes No
FEMALES ONLY Have you ever had a menstrual period? Yes No
How old were you when you had your first menstrual period? Yes No
How many menstrual periods have you had in the last year? Yes No
MALES ONLY Have you ever had an injury to a testicle or other reproductive organs? Yes No
Do you or have you had undescended testicles? Yes No
ENT Have you had multiple ear infections? Yes No
Do you have loss of hearing in one or both ears? Yes No
Have you had your tonsils or adenoids taken out? Yes No
7 ABDOMINAL Have you ever had an ulcer? Yes No
Do you have a history of gastrointestinal (GI) problems? Yes No
Do you experience abdominal pain multiple times per month? Yes No
Have you had your appendix removed? Yes No
UROLOGY Have you had multiple urinary tract /bladder infections? Yes No
Have you ever had a kidney infection? Yes No
Have you ever had kidney or gall stones? Yes No
PERSONAL HISTORY PLEASE ELABORATE ON ANY POSITIVE ANSWERS WITH ADDITIONAL COMMENTS IN THE SPACE PROVIDED BELOW. (ALL ANSWERS ARE CONFIDENTIAL) IF YOU HAVE ANY DR’S NOTES, PHYSICAL THERAPY NOTES, SURGERY NOTES, ETC OF A PAST INJURY, PLEASE SEND THEM WITH THIS PACKET OR BRING THEM WITH YOU TO MACALESTER! ______A. List any illness, injury, surgery, or hospitalization (gives dates and explain).
______B. Do you take medication routinely? Reason and Type: □ Yes No
______C. Do you have any food allergies or dietary restrictions?(i.e. vegetarian, lactose intolerant, gluten free, etc.) □ Yes No 8 ______D. Have you ever been diagnosed and/or treated for ADD/ADHD □ Yes No Do you currently take medication to help manage your ADD/ADHD? If yes, what do you take?
______E. Have you ever been diagnosed or treated for a mental health condition □ Yes No If yes, for which of the following conditions have you been diagnosed or treated? (please check all that apply)
□ Depression □ Bipolar Disorder □ Anxiety □ Anorexia or bulimia □ Substance abuse or dependency □ Other (please list: ______
______F. Do you currently take medication to help manage a mental health condition? □ Yes No If yes, what do you take?
______G. Have you ever been hospitalized for a mental health condition? □ Yes □ No
Please read and sign below before participation in any athletic activity.
I authorize the Health & Wellness Center to release a copy of my current health history record, physical examination and immunization records to the Athletic Medicine Department. This may be shared with my consent.
______Student’s Signature Birthdate Date
If you are under 18 please have your parent/guardian sign below. Students under 18 years of age must have parental permission to receive medical treatment or emergency care through our Health & Wellness Center. I give permission for my son/daughter to receive medical treatment or emergency care through the Health & Wellness Center. ______Parent/Guardian Signature
Macalester College MEDICAL EXAMINATION TO BE COMPLETED BY THE EXAMINING HEALTH CARE PROVIDER (i.e. MD, DO, NP, PA) RETURN TO: Paula Natvig, Head Athletic Trainer, 1600 Grand Ave., St. Paul, MN 55105
Student’s Name Date of Birth Age Gender
MEDICAL EXAMINATION – MUST BE COMPLETED WITHIN 6 MONTHS OF COMING TO MACALESTER
9 Height: ______Weight: ______BMI (optional) ______Arm Span ______(optional screen for Marfan Syndrome)
Pulse: ______BP: ______/______Hearing Screen: Right ______Left ______(Audiogram or confrontation)
Vision: R - 20/______L 20/ ______Corrected: Yes/No Contacts Yes/No Pupils: Equal ______Unequal ______
LAB (if necessary) Results: ______
EXAM NORMAL ABNORMAL (explain) Appearance Y/N HEENT Y/N Eyes Y/N Fundoscopic Y/N Pupils Equal/Unequal Ears/Nose Y/N Hearing Y/N Throat Y/N Dental Y/N Lymph Nodes Y/N Thyroid Y/N Lungs Y/N Abdomen Y/N Genitourinary (male) Y/N Hernia Y/N Skin Y/N Musculoskeletal Neck Y/N Back Y/N Shoulder/Arm Y/N Elbow/Forearm Y/N Wrist/Hand/Fingers Y/N Hip/Thigh Y/N Knee Y/N Leg/Ankle Y/N Foot/Toes Y/N Duck Walk Y/N Neurological Y/N Psychological Y/N CARDIAC Y/N Is patient under treatment of any kind at this time? □ Yes : □ No Explain:
Physical/Mental Disabilities or impairment? □ Yes : □ No Explain:
Please continue on to next page to complete, sign and date.
Macalester College INTERCOLLEGIATE SPORT MEDICAL CLEARANCE FORM
RETURN TO: Paula Natvig, Head Athletic Trainer, 1600 Grand Ave., St. Paul, MN 55105
Student Name: ______Date of Birth: ______Gender: ______
Anticipated sport(s) participation (see list below):______
10 Date of Examination: ______
I certify that the above student has been medically evaluated and is deemed to be physically fit to: (Check one box)
_____Participate in ALL Macalester Varsity or Club Sports
_____Not cleared for these specific sport activities (list all that apply) EXPLAIN: ______
______
_____Not cleared for ANY sports activities. EXPLAIN: ______
______
_____Requires further evaluation before a final recommendation can be made. EXPLAIN: ______
______
I have examined the above named student, reviewed their health history form and have completed the sports qualifying physical examination as requested.
Health Care Provider Signature: ______Printed Name: ______
Clinic Address: ______
Office Phone: ______Office Email: ______Office FAX: ______
MACALESTER COLLEGE SPORT ACTIVITIES 2014-15 Intercollegiate Sports Baseball Golf Tennis Basketball Soccer Track & Field Cross Country Softball Volleyball Football Swimming/Diving Water Polo (women)
MACALESTER COLLEGE INTERCOLLEGIATE ATHLETICS INSURANCE REQUIREMENTS
RETURN TO: Paula Natvig, Head Athletic Trainer, 1600 Grand Ave., St. Paul, MN 55105
Macalester College requires all students to demonstrate evidence of health insurance every year. Students must go online to either opt out of the college Health Insurance policy by providing information on coverage or waive in to purchase the policy that the College offers. In addition, all Macalester College intercollegiate student-athletes must provide evidence of insurance that includes coverage for athletically- related injuries and coverage of up to $90,000.00. This is a NCAA requirement and a prerequisite for practice and competition. No student will be allowed to participate in any way until such evidence of current insurance coverage is on file with the Macalester College Department of Athletics. The below Acknowledgement of Insurance Requirements form and photocopy of both sides, must be on file before a student can participate. Insurance must provide coverage up to a minimum of $90,000 and cover athletically-related injuries.
11 Macalester College will assume no responsibility whatsoever for the payment of, or authorization to pay medical expenses resulting from injuries that occur while participating in intercollegiate athletics at Macalester College.
If you have questions regarding the terms of your coverage, you should contact your insurer immediately. Please be sure to note if there are any exclusions in your policy regarding athletically-related injuries. Also, please be sure that your insurance will cover your student- athlete in the Twin Cities Metro Area of Minnesota. We do highly recommend that student-athletes consider enrolling in the student insurance policy offered by Macalester College through Aetna. This policy will give very good coverage of injury and illness while your student-athlete is living in St. Paul.
The NCAA’s Catastrophic Injury Insurance Program covers student-athletes who are catastrophically injured while participating in a covered intercollegiate athletic activity (subject to all policy terms and conditions). The policy has a $90,000 deductible. This coverage does not qualify as the basic coverage required for participation in athletics at Macalester College. It is supplemental coverage in the event of a catastrophic injury. More information on this program can be found on the NCAA’s web-site at www.ncaa.org If you have any questions regarding this requirement, please contact Paula Natvig at 651-696-6162 or [email protected]. Acknowledgement of Insurance Requirements
STUDENT ATHLETE MACALESTER DATE OF BIRTH SPORT COLLEGE ID
I, ______as parent, guardian, or legal representative attest that______(Name, please print) (Student-Athlete Name, please print) has insurance coverage under a current insurance policy for injuries that occur while he/she is participating in intercollegiate athletics. This policy covers claims to at least $90,000.
If there is a material change in coverage or expiration of coverage, I agree to notify Macalester College of this development and update the insurance information I have on file with Macalester College.
I understand and agree that Macalester College will assume no responsibility whatsoever for the payment of, or authorization to pay medical expenses resulting in injuries that occur while participating in intercollegiate athletics at Macalester College.
______(Parent Signature) (Date)
PLEASE ATTACH COPIES OF YOUR INSURANCE CARD BELOW
FRONT of Insurance Card BACK of Insurance Card (please secure all edges with glue or tape) (please secure all edges with glue or tape)
Student-Athlete Authorization/Consent for Disclosure of Protected Health Information
I, ______hereby authorize ____Macalester College______Name of Student-Athlete Name of my Institution
12 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, including, without limitation, injuries or illnesses resulting from or affecting training for or participation in athletics, may be disclosed to, and/or used by, the NCAA, and any third party expressly authorized by the NCAA to receive such information for the purposes described in this paragraph. The information provides NCAA committees, athletics conferences and individual schools and NCAA- approved researchers with injury, relevant illness and participation information that does not identify individual student- athletes or schools. The data provide the Association and other groups with an information resource upon which to base and 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.
I understand that my protected health information is 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) and may not be disclosed without either my authorization under HIPAA or my consent under the Buckley Amendment. I understand that my signing of this authorization/consent is voluntary and that my institution will not condition or withhold any health care treatment or payment, enrollment in a health plan or receipt of any benefits (if applicable) on whether I provide the consent or authorization requested for this disclosure. I also understand that I am not required to sign this authorization/consent in order to be eligible for participation in NCAA athletics. 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 protected health information and any personal identifiers will be encrypted while being transmitted from my institution and, to the extent kept by the NCAA, that all such data will be stored securely within industry standards. I further understand that neither the NCAA nor its agents or contractors will identify me personally in any publication or disclosure of research results. 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
Macalester College Sickle Cell Trait Form for NCAA Intercollegiate Athletics About Sickle Cell Trait Sickle cell trait is not a disease. Sickle cell trait is an inherited condition affecting the oxygen-carrying substance, hemoglobin, in the red blood cells. You are born with sickle cell trait; it cannot be developed over time or contracted like a disease. Sickle cell trait is a common condition (> three million Americans) Although Sickle cell trait occurs most commonly in African-Americans and those of Mediterranean, Middle Eastern, Indian, Caribbean, and South and Central American ancestry, persons of all races and ethnicities may test positive for this condition. 13 Those with sickle cell trait usually have no symptoms or any significant health problems. However, sometimes during very intense, sustained physical activity, as can occur with collegiate sports, certain dangerous conditions can develop in those with sickle cell trait, leading to blood vessel and organ (kidneys, muscles, heart) damage that can cause sudden collapse and death. Some of the settings in which this can occur include timed runs, all out exertion of any type for 2 to 3 continuous minutes without a rest period, intense drills and other bursts of exercise after doing prolonged conditioning training. Extreme heat and dehydration increase the risks. (NCAA: A Fact Sheet for Coaches, Sickle Cell Trait, http://web1.ncaa.org/web_files/health_safety/SickleCellTraitforCoaches.pdf) More information and resources regarding sickle cell trait and the NCAA’s recommendation for sickle cell trait testing can be found at the NCAA web site resource pages regarding the sickle cell trait, accessible at: www.NCAA.org/health‐ safety. Sickle Cell Trait Testing The NCAA recommends that all student-athletes have knowledge of their sickle cell trait status. Student-athletes must 1) show proof of a prior test with results; 2) have a blood test to check for sickle cell trait; or 3) sign a testing waiver declining options 1 and 2. Whichever option is chosen, it must be completed before the athlete participates in any intercollegiate athletics event, including strength and conditioning sessions, practices, competitions, etc. Macalester College recommends that all student-athletes who are unable to confirm their sickle cell trait status undergo sickle cell trait testing prior to participation in any intercollegiate athlete activity. Athletes who are positive for the trait will be allowed to participate in intercollegiate athletics; this does NOT prohibit you from playing. One of the following options must be chosen. Include any documentation if necessary: Copy of athlete’s newborn sickle cell testing result attached. ______Date: ______Most states require testing at birth, check with your hospital or pediatrician
Copy of recent sickle cell screening test result attached. ______Date: ______Cost of testing is the responsibility of the athlete SICKLE CELL TESTING WAIVER: By signing this waiver I understand and acknowledge that the NCAA recommends that all student-athletes have knowledge of their sickle cell trait status. Additionally, I certify that I have read and fully understand the aforementioned facts and I have had the opportunity to review the NCAA website for further information 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 the Macalester College Athletic Department. I do not wish to undergo sickle cell trait testing and I voluntarily agree to release, discharge, indemnify and hold harmless Macalester College, its officers, employees, agents and their successors and assigns from any and all costs, claims, damages or expenses, including attorneys fees, arising from any loss or personal injury that might result from my refusal to be tested.
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’s Signature Student-Athlete’s Print Name Date SPORT(s): ______Parent/Guardian’s Signature (if under 18 years of age) Parent/Guardian’s Print Name Date
CONSENT FOR TREATMENT AND AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
First Name Last Name Date of Birth Age
Sport(s) I understand that Macalester College employs Certified and Registered Athletic Trainers for the purposes of preventing, treating and educating student-athletes about injuries and illness that may be incurred 14 while participating in school-related athletic events and programs. As a student-athlete, I understand that I have to be an active participant in my own healthcare by reporting all of my injuries and illnesses to the Athletic Training Staff. I hereby affirm that I have fully disclosed in writing any prior medical conditions and will also disclose any future conditions to the Macalester College Athletic Training Staff.
I further understand that there is a possibility that participation in my sport may result in a head injury and/or concussion.
By signing below, I acknowledge that my institution has provided me with specific educational materials on what a concussion is, about the importance of immediately reporting symptoms and given me an opportunity to ask questions about areas and issues that are not clear to me on this issue. I also acknowledge that I have received and understand the educational information on Sickle Cell Trait and testing
In accordance with HIPAA guidelines, I give the following approvals for injuries resulting from participation at Macalester College in intercollegiate athletics. By my signature, I agree that the Macalester College Athletic Training staff can function with my approval of releases of injury or illness information. I also give my consent for treatment of my injuries by the Athletic Training staff This approval will last for one calendar year. I understand this authorization form must be filled out completely and signed in order to be considered valid.
A copy that has not been altered will be considered as valid as an original. I can at any time revoke this approval, to do so; it must be in a written form to the Macalester College Athletic Training staff.
I approve that the Macalester Athletic Training Staff can/may:
• Give injury/illness information from above sport(s) to the head and assistant coaches of the sport(s) I am involved in.
• Discuss my medical history with Macalester College team physicians, Macalester College Health and Wellness Center and other qualified medical providers when pertinent to my athletic participation.
• Email, mail, or fax information regarding my injuries/illness that are related to intercollegiate athletics to team physicians, referring physicians, Health and Wellness Center and/or my insurance company.
• Contact with the Office of Student Affairs staff for academic services, disability services, and other services as deemed needed. I understand that the Macalester College Athletic Trainers adhere to the “Notice of Privacy Practices” & this information can be viewed at www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/notice.html
I have read and understand the contents of this form Signature: Date: Parent’s Signature (if under the age of 18) Date:
15