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: ______SPORT(S): ______

If this form is NOT returned or is returned incomplete, you will be placed on Medical HOLD.

Please select one of the following: A. ______A copy of my newborn screening records pertaining to Sickle Cell Trait are attached (this test was mandated for all California newborns beginning in 1990. If you were born in another state, you will have to check their statute). If born in California use attached form to request records from the state. B. ______A copy of my Sickle Cell Trait test from a physician or other authorized medical care provider is attached. I acknowledge the results of the test to be: (please initial one of the following) Sickle Cell Trait Positive Initial ______Sickle Cell Trait Negative Initial ______C. ______I voluntarily decline to be tested, understand that an undiagnosed trait can be dangerous, even fatal, and agree to sign the waiver below. **IF YOU CHOOSE THIS OPTION YOU MUST SIGN THE WAIVER BELOW.

Sickle Cell Testing Waiver (only needed if option “C” is selected above): By signing this waiver, I am certifying that I understand that the NCAA recommends that all student-•‐athletes undergo testing for sickle cell trait. Furthermore, I have read and fully comprehend the aforementioned facts regarding sickle cell trait and the NCAA policy. By providing my signature below, I confirm that I have considered the information, understand it and that I do not wish to undergo testing for sickle cell trait. In consideration of this waiver, I hereby RELEASE, WAIVE, HOLD HARMLESS, DISCHARGE, INDEMNIFY, AND CONVENANT NOT TO SUE Holy Names University, its trustees, officers, agents, representatives or employees from any and all liability, claims, actions, demands, expenses, attorney fees, breach of contract actions, breach of statutory duty or other duty of care, warranty, strict liability actions and causes of action whatsoever, that may arise from my (or my minor child’s) decision to forego sickle cell testing. I hereby further agree that this Waiver and Release shall be construed in accordance with the laws of the State of California. I understand that I sign this Waiver and Release voluntarily, and that no oral representations, statements, or inducements, apart from the foregoing written document have been made to me on the subject matter of this document, that I am fully competent, and that I execute this Waiver for full, adequate and complete consideration fully intending for me (and my minor child) to be bound by the same. I further certify that I am at least eighteen (18) years of age and fully competent; or that if under eighteen (18) years of age, my parent or legal guardian is also signing individually and on my behalf and we both agree to be bound by the terms of the Sickle Cell Trait Testing Waiver and Release Form.

______Student-Athlete’s Signature Today’s Date of Signing

______Parent/Guardian’s Full Name (Printed) & Signature (if under 18) Today’s Date of Signing ASSUMPTION OF RISK & AGREE TO HOLD HARMLESS

I am aware that participation in any organized athletic event involves risk. That risk may include serious injury that could result in permanent disability or deformity, complete or partial paralysis, brain damage or even death. I can minimize the risk of injury to myself & others by making sure I am properly conditioned for my sport, following the instructions of the athletic trainers & coaches, obeying safety rules particular to my sport, wearing protective gear appropriate for my sport & reporting ALL injuries, regardless of how minor they might appear, immediately to the athletic trainer. I recognize that the potential for serious injury and its adverse effects will exist regardless of any preventative measures.

I hereby assume ALL risks associated with said participation and agree to hold Holy Names University, its employees, agents, representatives, coaches, athletic trainers and volunteers harmless from any and all liability, actions, causes of action, debts, claims or demands of any kind and nature whatsoever which may arise by or in connection with my participation in any activities related to my sport. The terms hereof shall serve as a release and assumption of risk for my heirs, estate, executor, administrator, assignees and for all members of my family.

______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

PERMISSION FOR MEDICAL CARE

In the event I sustain an injury while participating in athletics at Holy Names University, I hereby grant permission to the Athletic Trainer and/or the attending physician to provide emergency first aid or any other form of treatment they deem necessary (including evaluation, care, taping, bracing, rehabilitation, x-ray or other diagnostic tools, surgery etc.). I understand that follow-up care will be provided under the guidance of the Head Athletic Trainer and/or attending physician, following the policies and procedures set forth by the Holy Names University Athletic Training Staff.

______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

RELEASE OF RECORDS TO & FROM HOLY NAMES UNIVERSITY

I hereby authorize the Athletic Trainer and/or attending physician to request any medical or non-medical information pertinent to my intercollegiate competition at Holy Names University. I also hereby authorize the Athletic Trainer and/or attending physician to release such information regarding medical history, record of injury and rehabilitation results as may be requested by treating physicians, educational institutions, amateur athletic organizations or professional sports clubs. This release remains valid by me until revoked in writing.

______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 CONCUSSION SAFETY WHAT STUDENT-ATHLETES NEED TO KNOW

What is a concussion? A concussion is a type of traumatic brain injury. It follows a force to the head or body and leads to a change in brain function. It is not typically accompanied by loss of consciousness.

How can I keep myself safe? How can I be a good teammate? 1. Know the symptoms. 1. Know the symptoms. You may experience … You may notice that a teammate … • Headache or head pressure • Appears dazed or stunned • Nausea • Forgets an instruction • Balance problems or dizziness • Is confused about an assignment or position • Double or blurry vision • Is unsure of the game, score or opponent • Sensitivity to light or noise • Appears less coordinated • Feeling sluggish, hazy or foggy • Answers questions slowly • Confusion, concentration or memory problems • Loses consciousness

2. Speak up. 2. Encourage teammates to be safe. • If you think you have a concussion, stop playing • If you think one of your teammates has a and talk to your coach, athletic trainer or team concussion, tell your coach, athletic trainer or physician immediately. team physician immediately. • Help create a culture of safety by encouraging your 3. Take time to recover. teammates to report any concussion symptoms. • Follow your team physician and athletic trainer’s directions during concussion recovery. If left 3. Support your injured teammates. unmanaged, there may be serious consequences. • If one of your teammates has a concussion, let him • Once you’ve recovered from a concussion, talk or her know you and the team support playing it with your physician about the risks and benefits safe and following medical advice during recovery. of continuing to participate in your sport. • Being unable to practice or join team activities can be isolating. Make sure your teammates know they’re not alone.

No two concussions are the same. New symptoms can appear hours or days after the initial impact. If you are unsure if you have a concussion, talk to your athletic trainer or team physician immediately. NCAA | SPORT SCIENCE INSTITUTE | CONCUSSION SAFETY | WHAT STUDENT–ATHLETES NEED TO KNOW

What happens if I get a concussion and What do I need to know about repetitive keep practicing or competing? head impacts?

• Due to brain vulnerability after a concussion, • Repetitive head impacts mean that an individual has an athlete may be more likely to suffer another been exposed to repeated impact forces to the head. concussion while symptomatic from the first one. These forces may or may not meet the threshold of • In rare cases, repeat head trauma can result in brain a concussion. swelling, permanent brain damage or even death. • Research is ongoing but emerging data suggest that • Continuing to play after a concussion increases repetitive head impact also may be harmful and place the chance of sustaining other injuries too, not a student-athlete at an increased risk of neurological just concussion. complications later in life. • Athletes with concussion have reduced concentration and slowed reaction time. This Did you know? means that you won’t be performing at your best. • NCAA rules require that team physicians and • Athletes who delay reporting concussion take athletic trainers manage your concussion and injury longer to recover fully. recovery independent of coaching staff, or other non-medical, influence. What are the long-term effects of a • We’re learning more about concussion every day. To concussion? find out more about the largest concussion study ever conducted, which is being led by the NCAA and U.S. • We don’t fully understand the long-term effects of a Department of Defense, visit ncaa.org/concussion. concussion, but ongoing studies raise concerns. • Athletes who have had multiple concussions may have an increased risk of degenerative brain disease and cognitive and emotional difficulties later in life.

CONCUSSION TIMELINE

Baseline Concussion Recovery Return Return Testing If you show signs Your school has to Learn to Play Balance, cognitive of a concussion, a concussion Return to school Return to play and neurological NCAA rules management should be done only happens tests that help require that you plan, and team in a step-by-step after you have medical staff be removed from physicians and progression in returned to your manage and play and medically athletic trainers which adjustments preconcussion diagnose a evaluated. are required to are made as baseline and concussion. follow that plan needed to manage you’ve gone during your your symptoms. through a step-by- recovery. step progression of increasing activity.

For more information, visit ncaa.org/concussion. NCAA is a trademark of the National Collegiate Athletic Association.

Student-Athlete Concussion Statement

I understand that it is my responsibility to report all injuries to my athletic trainer and/or team ☐ physician.

I have read and understand the NCAA Concussion Fact Sheet. ☐ After reading the NCAA Concussion Fact Sheet, I am aware of the following information (please initial beside each statement):

______A concussion is a brain injury, which I am responsible for reporting to my team physician or athletic trainer.

______A concussion can affect my ability to perform everyday activities, and affect reaction time, balance, sleep, and classroom performance.

______You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury.

______If I suspect a teammate has a concussion, I am responsible for reporting the injury to my team physician or athletic trainer.

______I will not return to play in a game or practice if I have received a blow to the head or body that results in concussion-related symptoms.

______Following a concussion the brain needs time to heal. You are much more likely to have a repeat concussion if you return to play before your symptoms resolve.

______In rare cases, repeat concussions can cause permanent brain damage, and even death.

______Printed Name Signature Date

______Name of Parent/Guardian (if under 18) Signature of Parent/Guardian Date

2019-20 NCAA Banned Substances

It is the student-athlete’s responsibility to check with the appropriate or designated athletics staff before using any substance.

The NCAA bans the following drug classes.

a. Stimulants. b. Anabolic agents. c. Alcohol and beta blockers (banned for rifle only). d. Diuretics and masking agents. e. Narcotics. f. Cannabinoids. g. Peptide hormones, growth factors, related substances and mimetics. h. Hormone and metabolic modulators (anti-estrogens). i. Beta-2 agonists.

Note: Any substance chemically/pharmacologically related to all classes listed above and with no current approval by any governmental regulatory health authority for human therapeutic use (e.g., drugs under pre-clinical or clinical development or discontinued, designer drugs, substances approved only for veterinary use) is also banned. The institution and the student-athlete shall be held accountable for all drugs within the banned-drug class regardless of whether they have been specifically identified. Examples of substances under each class can be found at www.ncaa.org/drugtesting. There is no complete list of banned substances.

Substances and Methods Subject to Restrictions:

• Blood and gene doping.

• Local anesthetics (permitted under some conditions).

• Manipulation of urine samples.

• Beta-2 agonists (permitted only by inhalation with prescription).

• Tampering of urine samples.

NCAA Nutritional/Dietary Supplements:

Warning: Before consuming any nutritional/dietary supplement product, review the product and its label with your athletics department staff!

• Nutritional/Dietary supplements, including vitamins and minerals, are not well regulated and may cause a positive drug test.

• Student-athletes have tested positive and lost their eligibility using nutritional/dietary supplements.

• Many nutritional/dietary supplements are contaminated with banned substances not listed on the label.

• Any product containing a nutritional/dietary supplement ingredient is taken at your own risk.

Athletics department staff should provide guidance to student-athletes about supplement use, including a directive to have any product checked by qualified staff members before consuming. The NCAA subscribes only to Drug Free Sport AXISTM for authoritative review of label ingredients in medications and nutritional/dietary supplements. Contact the Drug Free Sport AXIS at 877-202-0769 or www.dfsaxis.com (password ncaa1, ncaa2 or ncaa3).

Some Examples of Substances in Each NCAA Banned Drug Class.

THERE IS NO COMPLETE LIST OF BANNED SUBSTANCES. DO NOT RELY ON THIS LIST TO RULE OUT ANY LABEL INGREDIENT.

Stimulants: amphetamine (Adderall); caffeine (guarana); cocaine; ephedrine; methamphetamine; methylphenidate (Ritalin); synephrine (bitter orange); dimethylamylamine (DMAA, methylhexanamine); “bath salts” (mephedrone); Octopamine; hordenine; dimethylbutylamine (DMBA, AMP, 4-amino methylpentane citrate); phenethylamines (PEAs); dimethylhexylamine (DMHA, Octodrine); heptaminol etc. exceptions: phenylephrine and pseudoephedrine are not banned.

Anabolic Agents (sometimes listed as a chemical formula, such as 3,6,17-androstenetrione): Androstenedione; boldenone; clenbuterol; DHEA (7-Keto); epi-trenbolone; testosterone; etiocholanolone; methasterone; methandienone; nandrolone; norandrostenedione; stanozolol; stenbolone; trenbolone; SARMS (ostarine, ligandrol, LGD-4033, S-23, RAD140)); DHCMT (oral turanibol) etc.

Alcohol and Beta Blockers (banned for rifle only): alcohol; atenolol; metoprolol; nadolol; pindolol; propranolol; timolol; etc.

Diuretics and Masking Agents: bumetanide; chlorothiazide; furosemide; hydrochlorothiazide; probenecid; spironolactone (canrenone); triameterene; trichlormethiazide; etc. exceptions: finasteride is not banned

Narcotics: Buprenorphine; dextromoramide; diamorphine (heroin); fentanyl, and its derivatives; hydrocodone; hydromorphone; methadone; morphine; nicomorphine; oxycodone; oxymorphone; pentazocine; pethidine

Cannabinoids: marijuana; tetrahydrocannabinol (THC); synthetic cannabinoids (e.g., spice, K2, JWH-018, JWH-073)

Peptide Hormones, growth factors, related substances and mimetics growth hormone(hGH); human chorionic gonadotropin (hCG); erythropoietin (EPO); IGF-1 (colostrum, deer antler velvet); etc. exceptions: insulin, Synthroid are not banned

Hormone and metabolic modulators (anti-estrogens) : anastrozole; tamoxifen; formestane; ATD; SERMS (clomiphene, nolvadex); Arimidex; clomid; evista; fulvestrant; aromatase inhibitors (Androst-3,5-dien-7,17-dione), letrozole; etc.

Beta-2 Agonists: bambuterol; formoterol; salbutamol; salmeterol; higenamine; norcoclaurine; etc.

Any substance that is chemically related to one of the above classes, even if it is not listed as an example, is also banned!

Information about ingredients in medications and nutritional/dietary supplements can be obtained by contacting Drug Free Sport AXIS, 877-202-0769 or www.dfsaxis.com password ncaa1, ncaa2 or ncaa3.

It is your responsibility to check with the appropriate or designated athletics staff before using any substance.

NCAA/06_11_2019/dks

Substance Screening Consent Form

Name of Student-Athlete: ______

Sport(s): ______Date: ______

Screening Procedures:

Holy Names University will conduct substance screening throughout the academic year. The basis for the screening is informed consent and 3rd party testing. Multiple on-campus screenings will occur throughout the year. Subsequent testing may be conducted at the discretion of the Athletic Director.

Selection of participant will be determined by random sampling and upon individualized reasonable suspicion: ● Observed changes in performance or behavior. ● Arrest on charges related to use and/or possession of banned substances. ● Suspected/manipulation of specimen. ● Proven history of positive results. ● Presence or possession by a Student-Athlete of illegal or controlled drugs or drug related paraphernalia. ● When a designated administrator, coach, or support staff has suspicion through sense of smell, sight and/or sound.

Consequences for a Positive Drug Test:

By signing this form, you affirm that you have been made aware of the institutional policies and that the consequences for a positive drug test are:

● First Positive Test o A minimum of one-week suspension from participation in practice, competition and travel. o The Student-Athlete must attend a conduct meeting with the Dean for Student Development and Engagement to determine whether further action is required. o The Student-Athlete may be able to begin participation again at the conclusion of seven days (since the Student-Athlete’s notification of positive test) depending on the recommendation of the assessment team and written evidence received by the Director of Athletics. o In some cases, the Student-Athlete must also be cleared for participation by the team physician and director of sports medicine. o The Student-Athlete will automatically be enrolled in substance screening process for the remainder of the school year.

● Second Positive Test o Suspension from participation in practice, competition, and travel for the rest of the current season. o The Student-Athlete may be terminated from any future participation in HNU Athletics. Athletic status, including scholarship eligibility, will be jeopardized. o The Student-Athlete must attend a conduct meeting with the Dean of Student Development and Engagement to determine whether further action is required.

Any offense may be grounds for revoking of athletic scholarship. The Director of Athletics must make recommendation on scholarship removal, with input from Head Coach, to the Vice President for Student Affairs and Enrollment Management.

Note: The decisions for both first and second violations will be decided by the Director of Athletics, Head Coach, and Dean for Student Development and Engagement. Any costs in addition to the scheduled substance screening will not be covered by HNU. The same corrective actions will occur for a Student-Athlete who is caught outside of the HNU Athletic Substance Screening Program in conjunction with the University conduct process.

Payment:

In the event a student-athlete is being drug tested on the basis of reasonable suspicion as a direct result of an HNU related violation, the student-athlete will be responsible for all payments associated with drug testing. Failure to do so will result in an automatic fail.

Signature: By signing below, I consent:

1. To be tested by HNU through the HNU Athletic Substance Screening Program which provides that: a. I will be notified of selection to be tested; b. I must appear at drug testing facility as directed or be sanctioned for a positive drug test; and c. I will be escorted by HNU Sports Medicine staff of the same gender to testing facility or during onsite execution of testing; 2. To accept the consequences of a positive drug test or a breach of drug testing protocol; 3. To allow disclosure of my drug-testing results only for purposes related to HNU Athletics and Institutional Policies.

I understand that if I sign this statement falsely or erroneously, I will violate the HNU Athletic Substance Screening Program and will jeopardize my eligibility.

Signature of Student-Athlete: ______Date: ______

Signature of Parent: ______Date: ______(if under the age of 18)

Name: ______DOB: ______Age:______

Address: ______

Phone: ______Email: ______NCAA Medical Exception Documentation Reporting Form To Support the Diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) And Treatment with Banned Stimulant Medication

 Complete and maintain (on file in the athletics department) this form and required documentation supporting the medical need for a student-athlete to be treated for ADHD with stimulant medication.  Submit this form and required documentation to Drug Free Sport in the event the student-athlete tests positive for the banned stimulant (see Drug Testing Exceptions Procedures at www.ncaa.org/drugtesting).

To be completed by the Institution:

Institution Name: Holy Names University

Institutional Representative Submitting Form: Name: Gloria Juarez, MA, ATC, CES, PES Title: Head Athletic Trainer Email: [email protected] Phone: 510-436-1248

Student-Athlete Name: ______Student-Athlete Date of Birth: ______

To be completed by the Student-Athlete’s Physician:

Current Treating Physician (Print Name): ______Specialty: ______Office Address: ______Physician Signature: ______Today’s Date: ______

Check off that documentation representing each of the items below is attached to this report: o Diagnosis. o Medication(s) and dosage. o Blood pressure and pulse readings and comments. o Note that alternative non-banned medications have been considered, and comments. o Follow-up orders. o Date of clinical evaluation: ______o Attach written report summary of comprehensive clinical evaluation. Please note that this includes the original clinical notes of the diagnostic evaluation. The evaluation should include individual and family history, address any indication of mood disorders, substance abuse, and previous history of ADHD treatment, and incorporate the DSM criteria to diagnose ADHD. Attach supporting documentation, such as completed ADHD Rating Scale(s) (e.g., Connors, ASRS, CAARS) scores. The evaluation can and should be completed by a clinician capable of meeting the requirements detailed above. DISCLAIMER: The National Collegiate Athletic Association shall not be liable or responsible, in any way, for any diagnosis or other evaluation made, or exam performed, in connection herewith, or for any subsequent action taken, in whole or in part, in reliance upon the accuracy or veracity of the information provided hereunder.

http://documentcenter.ncaa.org/msaa/saa/HealthandSafety/FormsTemplates/06142012ADHDreportingform.docx/RHB ASTHMA OR EXERCISE-INDUCED ASTHMA (EIA) NCAA Medical Exception Documentation for Holy Names University

• Complete and maintain this form regarding assessment and prescription medication for asthma or exercise induced asthmas (EIA). • This form will be submitted and all required documentation to Drug Free Sport in the event the student-athlete tests positive for the banned stimulant. Please see www.ncaa.org/drugtesting for any questions you may have.

Student-Athlete Name: ______Date of Birth: ______

TO BE COMPLETED BY THE STUDENT-ATHLETE’S PHYSICIAN:

Date of Clinical Evaluation: ______Diagnosis: ______

Peak Flow Measurements: ______Prescribed Medications and Dosage: ______

Were other medications considered? □ Yes □ No

Reasons for NOT using other medications: ______

Treating Physician (Print Name): ______Specialty: ______Office Address: ______Phone: ______Physician’s Signature: ______Today’s Date: ______

Please attach any notes you feel may clarify the student-athlete’s diagnosis and/or management of asthma/EIA. DISCLAIMER: The National Collegiate Athletic Association shall not be liable or responsible, in any way, for any diagnosis or other evaluation made, or exam performed, in connection herewith, or for any subsequent action taken, in whole or in part, in reliance upon the accuracy or veracity of the information provided hereunder. TO BE COMPLETED BY THE STUDENT-ATHLETE:

I, ______, give permission to ______(Print Your Name) (Print Name of Health Care Provider) To release all information regarding treatment for Asthma or EIA to the Holy Names University Athletic Training Staff and the National Collegiate Athletic Association. My signature below indicates that I have read and understand the above statement.

______Student-Athlete Signature Date

______Parent/Guardian Signature Date ______Circle year in school: 1st So Jr Sr 5th Sport(s)