Returning Student Athlete,

Participation with a Cal Poly NCAA team requires student athletes to complete the following printed forms and to sign into an online data entry system. Follow the check list below and if you have any questions please contact the Medicine staff. q Read through Insurance Letter.... q Print and sign Medical Consent form....

• Return all pages to Cal Poly Medicine q Print and sign Medical History Questionaire...

• Return all pages to Cal Poly Sports Medicine q Sign into SportsWare Online and complete required information...

• Follow the information sheet below.

• Update Insurance Information and upload current card.

All must be completed and reviewed by Sports Medicine Staff, before you are considered eligible for participation. Thank you and welcome to Cal Poly.

Your Cal Poly Sports Medicine Staff.

Direct questions to Paul Gabrielson at [email protected] 805-756-2096 Fax 805-756-7058

Cal Poly Athletic Training 1 Grand Avenue San Luis Obispo, CA 93407-0388 (805) 756-6065 ph. • (805) 756-7058 Fax

Dear Cal Poly Student Athletes and Parents, In an effort to manage insurance and medical expenses, the Department of Athletics requires that all student-athletes provide evidence of primary medical insurance before commencing intercollegiate practice or play. Failure to provide evidence of insurance coverage may prevent a student-athlete from participating in intercollegiate athletics’ activities. Please insure that the information on the attached questionnaire is completed accurately. In the event that the student-athlete is a member of a health maintenance organization, such as Kaiser Permanente or Blue Shield HMO, we are required to send the athlete to their primary care physician for treatment. We encourage student athletes to change their primary care physician to the San Luis Obispo area in order to expedite the process should they become injured. This is also beneficial for those athletes who have illnesses that the Student Health and Wellbeing Center is not equipped to handle.

The student athlete has access to many consultants at the Student Health and Wellbeing Center, such as medical services to treat illnesses, gynecology, pregnancy counseling, immunizations, health education, x-ray services, optometry, nutritional counseling, referrals to other health care agencies and psychological services. Some of these services may incur a medical cost to the student athlete; which is not covered by the athletic departments insurance.

Cal Poly Athletics participates in the California State University’s Risk Management Authority – Athletic Injury Medical Expense program (CSURMA- AIME). This program provides secondary (or excess) coverage for injuries sustained while participating in practice or play of intercollegiate athletics. This means that the student athlete’s primary insurance will be billed first in all cases, and the remaining amount, if any, will be submitted to the department’s secondary insurance for payment consideration. The first expense associated with athletic injury must be incurred within 120 days of the date of accident and only expenses incurred within 104 consecutive weeks from the date of accident will be reimbursed. Claims must be submitted within 18 months of the date of service for follow up treatment. Listed below are the procedures each student athlete must follow should they become injured: 1. All injury evaluation and follow-up care must be done through the Athletic Training Room (ATR). 2. When the student athlete is seen inside the ATR the athletic trainer will write out an injury report form. The student athlete will then be given instructions for care of the injury. This may include going to the Health Center or signing up to see one of the team physicians during the clinic hours in the ATR.

3. If it has been determined that the student athlete will require treatment off campus, a Notification of Injury form must be filled out. This form must be completed by the student athlete, and an athletic training staff member. Any student athlete who seeks non emergency medical care off campus for an athletically related injury without first consulting with the Athletic Training Room will not be covered by the Cal Poly insurance. 4. If the student athlete requires an off campus visit to a medical provider it must be coordinated through the athlete’s primary insurance. This may mean calling for authorization or visiting the primary care physician. 5. If the student athlete or the student athlete’s parents receive bills or explanation of benefits in the mail, they must be forwarded to: Kristal Slover Cal Poly Athletic Department San Luis Obispo, CA 93407-0388

If we do not have the itemized bills and explanation of benefits we cannot proceed with payment from the CSURMA-AIME Athletic Insurance. 6. Each injured student athlete’s medical status will be reviewed with the respective head coach on a regular basis to determine ability to participate. I have enclosed a Medical History Questionnaire along with the Insurance Information sheet. Please return these to your coaching staff or to the Athletic Training Room. Remember that the training room must have this information prior to any participation with your Cal Poly Team. I greatly appreciate your time and consideration in this matter. If you have any questions, please call Kristal Slover at (805) 756-6065. Sincerely,

Kristal Slover

Head Athletic Trainer Name: ______Sport:______

Returning Student-Athlete Annual Medical History Questionnaire Shared Responsibility for Sport Safety Participation in sports requires an acceptance to risk of injury. Athletes rightfully assume that those who are responsible for the conduct of sport have taken responsible precautions to minimize the risk of significant injury and that those participating in the sport will not intentionally inflict injury. Periodic analysis of injury patterns continuously lead to refinements in the rules and other safety guidelines. However, to legislate safety via the rule book and equipment standards, although often necessary, is seldom effective by itself. To rely on officials to enforce compliance with the rule book is as insufficient as to rely on warning labels to produce behavioral compliance with safety guidelines. Compliance means respect on everyone’s part for the intent and purpose of a rule or guideline, not merely technical satisfaction by some of its phrasing. This annual form must be completed and returned before the student-athlete will be permitted to practice or play. The National Collegiate Athletic Association’s (NCAA) policies recommend that all student-athletes have qualifying medical evaluations upon their initial entrance into an institution’s intercollegiate athletic program. Subsequent to the initial medical evaluation, an updated medical history should be performed annually. Further pre-participation physical examinations are not believed to be necessary unless warranted by the updated history. California Polytechnic State University, San Luis Obispo supports and adheres to this NCAA policy. Further medical evaluations (subsequent to the initial qualifying examination) may be required in specific cases. Date of Last Physical Examination: 20

Circle One 1. Have you been hospitalized or had a major illness since the initial physical examination? If yes: ______YES NO 2. Are you currently ill in any way? If yes: YES NO 3. Have you had a major injury since the initial physical examination? If yes: YES NO 4. Do you currently have any incompletely healed injuries? If yes: YES NO 5. Are you taking any medication on a regular or continuing basis? If yes: YES NO 6. Are you currently taking any short-course medication for a specific YES NO current injury or illness? If yes: 7. Have you had any operations or surgeries since the completion of the YES NO Spring quarter? If yes: 8. Have you experienced a concussion in the last 12 months? YES NO Have you repeated baseline concussion testing since your last concussion? 9. Have you had any accidents and/or other trauma since the completion of YES NO Spring quarter? If yes: YES NO 10. Have you seen a physician for any reason since the completion of Spring quarter? If yes: YES NO 11. Do you believe there is any health reason why you should not participate in the CPSU Intercollegiate Athletic Program at this time? If yes: YES NO The undersigned, herewith: A. Understands that he or she must refrain from practice while ill or injured, whether or not receiving medical treatment until he or she is discharged from treatment or is given permission by the clinical practitioner to restart participation despite continuing treatment. B. Understands that having passed the physical examination does not necessarily mean that he or she is physically qualified to engage in athletics, but only that the evaluator did not find a medial reason to disqualify him or her at the time of the examination. C. Certifies that the answers to the above questions are correct and true. Date: Signature of Student-Athlete:

Physician’s Evaluation If you have suffered an injury or illness in the last 12 months, where you missed competition or practice. You must complete the following physical or have a clearance to return to participation from your treating physician on file in the athletic training room. No clearance Cleared for return to participation with no restrictions. Cleared for return to participate with restrictions, conditions, or special instructions as follows:

Physician’s Signature M.D. Date:

TO BE COMPLETED BY CPSU ATHLETIC TRAINING STAFF This form has been reviewed by the athletic training staff. [ ] Athlete needs to be referred for an evaluation of the following condition(s) by a physician:

Referred to M.D. Physician A.T.C. Date: Signature of NATA Certified Athletic Trainer Cal Poly Sports Medicine 1 Grand Avenue, San Luis Obispo, CA 93407 (805) 756-6065 ph. • (805) 756-7058 Fax

Medical Consent Directions: I. Please read carefully and sign the following consent forms. If you are under 18 years of age, your parents must also sign. II. If you choose to refuse to sign any of these consent forms, please write “Refuse to Sign” and date and sign the form. Please return and provide the signed form to your athletic trainer. The signed form must be returned to your athletic trainer before you are permitted to participate. III. This document will remain in effect for one year of signing. Any portion may be revoked at the discretion of the student-athlete by notifying your athletic trainer. Any such notification must be in writting. Basic Content: I. Medical Consent: Allows athletic trainers and physicians to treat any injury or illness you sustain while an athlete at Cal Poly State University. II. Disclosure of Protected Medical Information: Allows those listed to disclose injury and illness information due to participation in intercollegiate athletics to those listed. III. Release of Information to Professional Sports: Allows those listed to release any and all information concerning you, including medical records and other items listed. IV. Blood Borne Pathogens: Acknowledges that exposure and transmission of Blood Borne Pathogens is possible through athletics and that you are willing to assume responsibility. V. Assumption of Risk: Acknowledges that all athletic activity affords a certain amount of risk of injury and that you are aware of these risks and the rules of your sport intended to minimize these risks.

I. Medical Consent

I hereby grant permission to the Cal Poly State University team physician and/or their consulting physician to render to my son or daughter or myself any treatment or medical or surgical care that they deem reasonably necessary to the health and well being of the student-athlete.

I also hereby authorize the athletic training staff at Cal Poly State University who are under the guidance of the team physician, to render to my son or daughter or myself any preventative, first aid, rehabilitative or emergency

26 treatment that they deem reasonably necessary to the health and well being of the student-athlete.

Also, when necessary for executing such case, I grant permission for hospitalization at an accredited hospital.

If the student-athlete is under 18 years of age, a parent or guardian signature is required.

Date: Signature of Student-Athlete

Date: Signature of Parent or Guardian

II. Authorization/Consent for disclosure of Protected Health Information

I hereby authorize the physicians, certified athletic trainers, sports medicine staff, student health center staff, student counseling center staff and other health care personnel representing Cal Poly State University to release information regarding my protected health information and any related information regarding any injury or illness during my training for and participation in intercollegiate athletics. This protected health information may be released to other health care providers, parents/guardians, hospitals and/or medical clinics and laboratories, athletic coaches, strength and conditioning coaches, medical insurance coordinators, insurance carriers, medical supply vendors and/or service companies, academic counselors, athletic and/or university administrators, NCAA Injury Surveillance System, sports information staff and members of the media. I understand that my authorization/consent for the disclosure of my protected health information is a condition for participation as an intercollegiate athlete at Cal Poly State University. 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 once information is disclosed per my authorization/consent, the information is subject to re-disclosure and may no longer be protected by HIPAA and/or the Buckley Amendment.

27 I understand that I may revoke this authorization/consent at any time by notifying in writing the Head Athletic Trainer, but if I do, it will not have any effect on actions Cal Poly State University took in reliance on this authorization/consent prior to receiving the revocation. This authorization/consent expires 380 days from the date it is signed.

If the student-athlete is under 18 years of age, a parent or guardian signature is required.

Date: Signature of Student-Athlete

Date: Signature of Parent or Guardian

III. Authorization for Release of Medical Information for Employment in Professional Sports

I, , hereby authorize and request the Cal Poly State University Sports Medicine Department to supply to professional athletic teams, their scouts, representative agents, athletic trainers, physicians, or employees, any and all medical information concerning or having bearing upon my participation in intercollegiate athletics at Cal Poly State University. This authorization shall include, but not limited, to any and all information within their knowledge, or contained in any medical records under their supervision or control concerning my physical condition, illness, injuries, and any treatment, hospitalization, examinations, x-rays, and to make such reports to such persons or organizations concerning myself that they may request; and I hereby fully discharge all parties to whom this authorization extends from any and all privilege in connection with the disclosure of information included in this authorization.

If the student-athlete is under 18 years of age, a parent or guardian signature is required.

Date: Signature of Student-Athlete

Date: Signature of Parent or Guardian

28 IV. Blood-Borne Pathogens and Intercollegiate Athletics (Copyright, 1997, by the NCAA)

Blood-Borne pathogens are disease-causing microorganisms that can be potentially transmitted through blood contact. The blood-bone pathogens of concern include (but not limited to) the hepatitis virus (HBV) and the human immunodeficiency virus (HIV). Infection with these viruses has increased throughout the last decade among all portions of the general population. These diseases have potential for catastrophic health consequences. Knowledge and awareness of appropriate preventative strategies are essential for all members of society, including student-athletes.

The particular blood-borne pathogens HBV and HIV are transmitted by practicing risky unprotected sexual contact (heterosexual and homosexual), direct contact with infected blood or blood components, and perinatally from mother to baby. Experts have concurred that the risk of transmission on the athletic field is minimal.

HBV is a blood-borne pathogen that can cause infection of the liver. Many of those infected will range from no symptoms to a mild flu-like illness. One third will have severe hepatitis, which cause the death of one percent of that group. Currently, in the United States there are one million chronic carriers of HBV. Chronic complications of HBV infections include cirrhosis of the liver and liver cancer. The incidence of HBV in student-athletes is presumably low, but those practicing risky behaviors off the athletic field have an increased likelihood of infection (just as in the case of HIV). An effective vaccine to prevent HBV is available and recommended for all college students by the American College Health Association.

The Acquired Immunodeficiency Syndrome (AIDS) is caused by HIV, which infects cells of the immune system and other tissues such as the brain. Some of those infected will remain asymptomatic for many years. Others will more rapidly develop the manifestation of the HIV disease (i.e. AIDS). Some experts believe virtually all persons infected with HIV will eventually develop AIDS, which is fatal. In the United States there are 40,000 to 50,000 newly infected persons each year. There are 1.5 million infected persons in the United States. The risk of infection is increased by having unprotected sexual intercourse and sharing IV needles. Currently, there is no vaccination available to prevent HIV.

HBV is a more “sturdy/durable” virus than HIV and is more highly concentrated in blood. HBV is more likely to be transmitted by exposure to infected blood, particularly with needle-stick exposure, but also exposure to open wounds and mucus membranes. The risk of transmission for either HBV or HIV is considered minimal; however, most experts agree that the specific epidemiological and biologic characteristics of the viruses make them a realistic concern for transmission in sports with sustained close physical contact.

Cal Poly State University sports medicine staff acknowledges the risks and utilizes Universal Precautions as recommended by the Center for Disease Control, the NCAA Sports Medicine Handbook and OSHA to minimize the risk of blood-borne pathogen exposure and transmission on the context of athletic events and treatment guidelines for the health care of student- athletes.

I have carefully read and fully understand the risk of blood-borne pathogens exposure and transmission.

If the student-athlete is under 18 years of age, a parent or guardian signature is required.

Date: Signature of Student-Athlete

Date: Signature of Parent or Guardian

30 V. RELEASE OF LIABILITY, PROMISE NOT TO SUE, ASSUMPTION OF RISK AND AGREEMENT TO PAY CLAIMS

Sport: ______

School Year: ______In consideration for being allowed to participate in this Activity, on behalf of myself and my next of kin, heirs and representatives, I release from all liability and promise not to sue the State of California, the Trustees of The California State University, California Polytechnic State University, the Cal Poly Corporation, and their employees, officers, directors, volunteers and agents (collectively “University”) from any and all claims, including claims of the University’s negligence, resulting in any physical or psychological injury (including paralysis and death), illness, damages, or economic or emotional loss I may suffer because of my participation in this Activity, including travel to, from and during the Activity.

I am voluntarily participating in this Activity. I am aware of the risks associated with traveling to/from and participating in this Activity, which include but are not limited to physical or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability (including paralysis), economic or emotional loss, and/or death. I understand that these injuries or outcomes may arise from my own or other’s actions, inaction, or negligence; conditions related to travel; or the condition of the Activity location(s). Nonetheless, I assume all related risks, both known or unknown to me, of my participation in this Activity, including travel to, from and during the Activity.

I agree to hold the University harmless from any and all claims, including attorney’s fees or damage to my personal property that may occur as a result of my participation in this Activity, including travel to, from and during the Activity. If the University incurs any of these types of expenses, I agree to reimburse the University. If I need medical treatment, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.

I am 18 years or older. I understand the legal consequences of signing this document, including (a) releasing the University from all liability, (b) promising not to sue the University, (c) and assuming all risks of participating in this Activity, including travel to, from and during the Activity.

I understand that this document is written to be as broad and inclusive as legally permitted by the State of California. I agree that if any portion is held invalid or unenforceable, I will continue to be bound by the remaining terms.

I have read this document, and I am signing it freely. No other representations concerning the legal effect of this document have been made by me.

Participant Signature: ______

Participant Name (print): ______Date: ______

If Participant is under 18 years of age, the following page is also required.

Revised September 26, 2012 RELEASE OF LIABILITY, PROMISE NOT TO SUE, ASSUMPTION OF RISK AND AGREEMENT TO PAY CLAIMS

If Participant is under 18 years of age:

I am the parent or legal guardian of the Participant. I understand the legal consequences of signing this document, including (a) releasing the University from all liability on my and the Participant’s behalf, (b) promising not to sue on my and the Participant’s behalf, (c) and assuming all risks of the Participant’s participation in this Activity, including travel to, from and during the Activity. I allow Participant to participate in this Activity. I understand that I am responsible for the obligations and acts of Participant as described in this document. I agree to be bound by the terms of this document.

I have read this document, and I am signing it freely. No other representations concerning the legal effect of this document have been made by me.

______Signature of Minor Participant’s Parent/Guardian

______Name of Minor Participant’s Parent/Guardian (print)

______Minor Participant’s Name Date

Revised September 26, 2012 SportsWare Directions New Athletes • Please log onto www.swol123.net and select the Join SportsWare (blue tab middle left side of page) enter the school code () then follow the directions • Be sure to use your @calpoly.edu email • Once you press send we will have to accept you. Once we accept, you will enter your Cal Poly email address in the email box. • Next click on RESET PASSWORD. An email will be sent to you giving instructions on how to reset the password • Once your password has been reset, log onto SportsWare, click on "My info" and fill out all the information under each tab beginning with "General", "Address", "Emergency", "Insurance", and "Medical" • Next Click on “Medical History” and fill out all questions. If you answer YES to any, explain in section given to the right. • Next click on “Forms” section and complete ADHD and Concussion History forms. Upload copies of PPE, sickle cell paperwork, and any other Sports Medicine Paperwork. • If you have had an Orthopedic Surgery in the last 4 years, please upload surgery, imaging, rehabilitation, and clearance to return to sport notes related to surgery.

All of these tabs must be completed for you to be cleared to play for the season.

RETURNING ATHLETES

• Please log onto www.swol123.net and enter your Cal Poly email address in the email box • If you have forgotten your password click on RESET PASSWORD an email will be sent to you giving instructions on how to reset your password • Once your password has been reset, log onto SportsWare, click on "My info" and fill out and update all information under each tab beginning with "General", "Address", "Emergency", "Insurance", "Medical", and “Forms” complete ADHD form (yearly) • For most of you your information is already in the system • DOUBLE CHECK IT TO MAKE SURE IT IS ALL CURRENT AND CORRECT!

AGAIN, ALL OF THIS MUST BE COMPLETED IN ORDER FOR YOU TO BE CLEARED TO PLAY FOR THE SEASON December 2017

Dear Student Athlete

Prior to participating on a team for Cal Poly State University, athletes must provide the Cal Poly Sports Medicine Department with current address, emergency contact, insurance, medical alert and health history information. To expedite this process Cal Poly uses an online data entry system.

To begin, visit www.swol123.net. The first time you visit the website you will need to enter “Join SportsWare” using the instructions below (SCHOOL ID: Cal Poly Mustangs).

Joining SportsWare OnLine

Instruction Example Go to www.swol123.net.

Scroll to the middle of the screen and click the Join SportsWare button.

Enter your School ID

Cal Poly Mustangs

This is required to join the correct school.

Enter your First Name, Last Name, Email address and click the Send button.

Your request to join SportsWare will then be sent to the Athletic Trainer for review.

Once your request is accepted you will receive an e-mail with the Subject “SportsWare request accepted”.

Open the e-mail and click the www.swol123.net link to continue to SportsWareOnLine. Setting Your Password Instruction Example Go to www.swol123.net

Enter your Email Address and click the Reset Password button.

You will receive and e-mail with the Subject “SportsWareOnLine Password Request”.

Open the e-mail and click on the link to reset your password. Enter your e-mail address, new password and click the Save button.

Updating Your Information Instruction Example Go to www.swol123.net

Enter your Email Address and click the Login button.

At the top of the page is the Menu Bar.

My Info: Update your address, emergency contact and insurance information.

Med History: Complete a Medical History questionnaire.

Forms: View/complete required paperwork. Note: SportsWare will also display “You have ? forms to complete/download”.

Print: Print My Info and Medical History data.

Thank you for your prompt help. If you have any questions, please contact the Paul Gabrielson at [email protected] or 805-756-2096 for assistance.

Sincerely,

Cal Poly Sports Medicine Team