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Returning Student-Athlete Checklist Part 1

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Returning Student-Athlete Checklist Part 1 RETURNING STUDENT-ATHLETE CHECKLIST PART 1: The following documents must be completed by all incoming student-athletes: Save the PDF to your computer and complete/resave using the latest version of Adobe Acrobat Reader. Student-Athlete Emergency Card Student-Athlete Insurance Sickle Cell Trait Assumption of Risk, Permission to Treat, Release of Records Concussion Statement Substance Screening Notification Make a clear copy of front and back of insurance card (save as PDF) PART 2: The following forms must be completed by student-athletes that have been diagnosed with ADHD and/or asthma AND are currently under the care of a physician for either condition and/or are currently taking prescribed medication for either condition (complete all that apply): NCAA Medical Exception Documentation (ADHD) Reporting Form—to be completed by physician Asthma or Exercise-Induced Asthma (EIA) Form—to be completed by physician STUDENT ATHLETE EMERGENCY INFORMATION Student-Athlete Name: Sport(s): Student-Athlete Cell Phone Number: Date of Birth: Social Security Number: Academic Year Address: Permanent Home/Mailing Address: Primary Insurance Policy—Member ID/Subscriber Number (NOT Group Number): Emergency Contact Name: Relationship to Athlete: Phone Number: Emergency Contact Address: Medications: Any Known Allergies: History of Medical Conditions: STUDENT-ATHLETE INSURANCE INFORMATION TO BE USED FOR MEDICAL CLAIMS PART 1: Student-Athlete Name: Sport(s): Student-Athlete Cell Phone Number: Date of Birth: Social Security Number: Academic Year Address: Permanent Home/Mailing Address: Primary Insurance Policy—Member ID/Subscriber Number (NOT Group Number): PART 2: Who is your primary insurance policy through (check one only): □ Father □ Mother □ Other ______________________ YOU MUST ATTACH A COPY OF BOTH THE FRONT AND BACK OF YOUR CURRENT INSURANCE CARD(S) AND FILL OUT THE INFORMATION BELOW BASED ON YOUR PREVIOUS SELECTION. DO NOT LEAVE ANYTHING BLANK. Policy Holder Name: Home Address: Home Phone/Cell Phone: Employer Name: □ Retired Employer Address: Employer Phone: Insurance Company Name: Is this insurance plan an HMO, Medi-Cal, or Kaiser Permanente? IF YES, HNU RECOMMENDS YOUR POLICY BE TRANSFERRED TO NORTHERN CA (KAISER PATIENTS) OR ALAMEDA COUNTY, AND □ Yes □ No MUST BE ACTIVE PRIOR TO PARTICIPATION IN YOUR SPORT(S). Who is your secondary insurance policy through (check one only): □ Father □ Mother □ Other ____________________ □ N/A Policy Holder Name: Home Address: Home Phone/Cell Phone: Employer Name: □ Retired Employer Address: Employer Phone: Insurance Company Name: Is this insurance plan an HMO, Medi-Cal, or Kaiser Permanente? IF YES, HNU RECOMMENDS YOUR POLICY BE TRANSFERRED TO NORTHERN CA (KAISER PATIENTS) OR ALAMEDA COUNTY, AND □ Yes □ No MUST BE ACTIVE PRIOR TO PARTICIPATION IN YOUR SPORT(S). Student-Athlete Insurance Information - Page 1 STUDENT-ATHLETE INSURANCE INFORMATION (Cont’d) FOR STUDENT-ATHLETES THAT ARE SELF-INSURED: Are you currently employed? □ Yes □ No Is your insurance coverage from your place of employment? □ Yes □ No □ N/A Employer Name (if applicable): Employer Address (if applicable): Employer Phone (if applicable): Insurance Company: Is this insurance plan an HMO, Medi-Cal, or Kaiser Permanente? IF YES, HNU RECOMMENDS YOUR POLICY BE TRANSFERRED TO NORTHERN CA (KAISER PATIENTS) OR ALAMEDA COUNTY, AND □ Yes □ No MUST BE ACTIVE PRIOR TO PARTICIPATION IN YOUR SPORT(S). **If the student-athlete’s primary insurance is an HMO or through Medi-Cal, the HNU Sports Medicine Department strongly encourages the student- athlete and/or his/her parent(s) / guardian(s) change the primary care physician (PCP) to a physician in Alameda County; or, if through Kaiser Permanente, to apply for a Northern CA identification medical number. This will allow the student-athlete to have a network of physicians in Alameda County, as well as better access to care. Please contact an HNU certified athletic trainer if assistance is needed in this process. PART 3: By providing my initials: _________ I understand that as an HNU student-athlete, I must be covered by some type of individual health insurance policy before participating in any practice, game, and/or competition. Furthermore, I understand that my insurance must cover athletics related injuries and/or illnesses, and shall be considered the PRIMARY insurance coverage for all athletic related injuries. FOR INTERNATIONAL STUDENT-ATHLETES: I understand that I must purchase health insurance that is active in the United States and meets all the aforementioned requirements. _________ I understand that HNU provides a medical and catastrophic insurance program for its student-athletes. THIS POLICY, HOWEVER, IS SECONDARY TO, OR IN EXCESS OF, PERSONAL FAMILY MEDICAL INSURANCE COVERAGE, and covers only injuries / accidents resulting from the direct participation in the intercollegiate athletics program during the dates of the primary competitive season and designated off- seasons as approved by the Director of Athletics according to NCAA regulations. I understand that I may be responsible for up to $1,000 out-of-pocket, per injury, to meet the required deductible for HNU’s insurance program. Furthermore, I understand that general medical conditions are not covered by HNU nor its secondary insurance programs. _________ I understand that the HNU Sports Medicine Department must receive any plan or status changes to my health insurance policy as soon as it occurs. If change or cancellation of a policy occurs without proper notification, I understand that HNU, the HNU Athletics Department, and the HNU Sports Medicine Department will not be responsible for any medical charges, nor delays in payment, collections notices, credit reports, etc., that occur, and that I and/or my parent(s) / guardian(s) will assume full responsibility for any and all medical charges incurred during that time period. Furthermore, I understand that not having an active primary health insurance policy may result in my inability to participate with my sport(s). _________ I understand that I must be seen and evaluated by an HNU certified athletic trainer before a referral to a physician will be made. I also understand that an HNU certified athletic trainer must authorize and properly refer all student-athletes to see a physician or medical consultant, and/or for diagnostic tests. Furthermore, I understand that if I decide to see a physician / medical consultant, and/or undergo a diagnostic test WITHOUT prior authorization / referral from a member of the HNU Sports Medicine Department, I and/or my parent(s) / guardian(s) will be financially responsible for any and all medical bills incurred. _________ If I and/or my parent(s) / guardian(s) desire the opinion of another physician outside of the HNU Sports Medicine Team and/or without the authorization of an HNU certified athletic trainer, I understand that I have the right to that pursuit. I also understand that by doing so, I and/or my parent(s) / guardian(s) will be financially responsible for any and all medical bills incurred for those unauthorized services. I hereby state that, to the best of my knowledge, my answers to all requested information are complete and correct. ___________________________________________________________________ _______________________________ Student-Athlete’s Name (Printed) & Signature Today’s Date of Signing ___________________________________________________________________ _______________________________ Parent/Guardian’s Full Name (Printed) & Signature (if under 18) Today’s Date of Signing Student-Athlete Insurance Information - Page 2 SICKLE CELL TRAIT—REPORTING 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/Central American ancestry, persons of all races and ancestry may test positive. An undiagnosed trait can be dangerous, even fatal. 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 and possible death. Twenty-one college football players with Sickle Cell Trait have collapsed and died over the past decade. If an athlete tests positive, he or she will still be able to participate in athletics activities with certain precautions. More information on Sickle Cell Trait may be found at the following NCAA website: http://www.ncaa.org/health-and-safety/medical-conditions/sickle-cell-trait/ Sickle Cell Trait Testing: • The NCAA has mandated that all Division II student-athletes be tested for Sickle Cell Trait, show proof of a prior test, or sign a waiver releasing the school from liability if they decline to be tested before participating in athletic-related activities, including intercollegiate athletics events, strength and conditioning sessions, practices, competitions, etc. • Please PRINT your name, date of birth, and sport(s) below. Select one of the options below and return this form to: ATTN: HNU Sports Medicine – Gloria Juarez, Holy Names University Athletics, 3500 Mountain Blvd, Oakland CA 94619 Name: ________________________________________ DOB: _______________
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