TRYOUT REQUEST COVERSHEET FOR PROSPECTIVE STUDENT

Transcription

1 TRYOUT REQUEST COVERSHEET FOR PROSPECTIVE STUDENT To be completed by Student prior to tryout Name Date Date of Birth Sport School Currently Attending Registered with NCAA Eligibility Center o Yes o No ID# address Required document checklist I have completed/attached the following required documentation (5 items total): Document 1. Tryout Request Coversheet for Prospective Student 2. Participation Waiver (signed and dated) *Also signed by Parent/Guardian if student is under 18* 3. Sickle Cell Trait Test Waiver (or results of Sickle Cell Test) *Also signed by Parent/Guardian if student is under 18* 4. Seawolves Sports Medicine Physical Exam *All fields complete, physician s signature/stamp* *Physical exam must have occurred within last 6 months* 5. Copy of current proof of insurance Participant Initials Acknowledgements I certify that this tryout is occurring on or after June 15 th following my sophomore year in High School. I understand that I am allowed to participate in only one tryout per sport at Sonoma State University. I understand this tryout must occur outside of my High School playing season, and must not exceed two hours in duration. Further, I agree to comply with all rules/regulations set forth by Sonoma State University, the relative conference, and NCAA. Signature: ITEM 1

2 PARTICIPATION WAIVER Waiver of Liability, Covenant Not to Sue, Assumption of Risk & Release Full Name (please print): Sport: I, the undersigned, hereby acknowledge that participation in athletic activities involves an inherent risk of physical injury. The undersigned hereby agrees, for the sole consideration of Sonoma State University allowing the undersigned to participate in athletic activities for which or in connection with the college sponsored or made available any equipment, facilities, grounds, or personnel for such activities or to the undersigned while participating in any such programs or activities, the undersigned does hereby release and forever discharge Sonoma State University, its members officially and individually, and its officers, agents, and employees of any and all claims, demands, rights, and causes of action of whatever kind or nature, arising from any injuries, damage to property, and the consequences thereof, including death, resulting from my participation in any way connected with such athletic activities. Further, in consideration of being allowed to participate in a sports tryout and/or any other related events and activities for the Intercollegiate Athletics program at Sonoma State University, the undersigned: a. Represents that s/he have not participated in more than one tryout per institution per sport; b. Understands their participation is being granted based upon having passed a medical examination or evaluation administered or supervised by a physician (e.g., family physician, team physician) and that the examination or evaluation was administer within six months prior to participating in the tryout; c. Acknowledges that since the date of this physical examination s/he is not currently under any restricted physician care for a new injury or medical condition that could lead to injury. (If a new injury or medical issue which affects athletic performance has been sustained or if s/he is currently under the care of a physician for any medical condition or injury, please check this box [ ]. If box is checked, an appropriate note from the treating physician indicating diagnosis and appropriateness of sports participation must be provided with this release in order to proceed with a tryout). d. Acknowledges and fully understands that s/he will be engaging in activities that involve risk of potential serious injury including but not limited to, possible permanent disability or death, possible severe social and economic losses which might result not only from my actions, inactions or negligence, but the actions or negligence of others, the rules of play or condition of the premises or of any equipment used; e. Understands that s/he is responsible through personal resources or appropriate insurance coverage for any medical costs incurred respective to all the foregoing risk and accepts responsibility for any and all damages resulting from or as a consequence of participation in this tryout opportunity; Therefore, in consideration of the opportunity to participate in this tryout activity, the undersigned: a. Voluntarily and freely assumes all risks of loss, damage, illness, injury or death that may be sustained from participation in University or Department of Intercollegiate Athletic activities; b. Covenants to refrain from instituting any claim, demand or cause of action for damages, costs of medical expense or other compensation against CSU, Sonoma State University, the Department of Intercollegiate Athletics and their officers, agents or employees and agree to release and hold them harmless from any and all liability to s/he, their heirs, or next of kin, as a result of s/he s participation in any University activities; c. Has read and understands the content of this waiver release and signs voluntarily. I, the undersigned, acknowledge that I am at least 18 years of age; OR IF UNDER 18, must have signed permission below from my custodial parent to participate in this tryout. Student Signature: Custodial Parent/Guardian Signature: ITEM 2

3 SICKLE CELL TRAIT TEST WAIVER About Sickle Cell Trait Sickle cell trait is an inherited condition of the oxygen-carrying protein, hemoglobin, in the red blood cells. Although Sickle cell trait is most predominant in African-Americans and those of Mediterranean, Middle Eastern, Indian, Caribbean, and South and Central American ancestry, persons of all races and ancestry may test positive for sickle cell trait. Sickle cell trait is usually benign, but 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. In rare severe cases, exertional sickling has led to the death of athletes with this trait. Sickle Cell Trait Testing The NCAA recommends that all student-athletes at the Division I and II levels have knowledge of their sickle cell trait status before the student-athlete participates in any intercollegiate athletics event, including strength and conditioning sessions, practices, competitions, etc. All individuals born in California on or after 2/26/90 should have been screened for sickle cell at birth and should use the following website to obtain their results: as soon as possible. They should then provide a copy of these results to the SSU Sports Medicine Department. For currently enrolled SSU students only: If you were not born in California or if you were born before 2/26/90 Sonoma State University Student Health Center offers sickle cell trait screening in the form of a blood test to all Sonoma State University students. Individuals that test positive for sickle cell trait will be counseled on what can be done to avoid complications and to provide optimal care of you during practice, competition, and conditioning. ITEM 3

4 SICKLE CELL TRAIT TEST WAIVER Athlete Acknowledgements I,, understand and acknowledge that the NCAA and Athlete Name (Print Name) Sonoma State University Department of Intercollegiate Athletics recommends that all student-athletes have knowledge of their sickle cell trait status. Additionally, I have read and fully understand the aforementioned 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 Sonoma State University Intercollegiate Athletics personnel. I do not wish to undergo sickle cell trait testing as part of my pre-participation physical examination and I voluntarily agree to release, discharge, indemnify and hold harmless Sonoma State University, the CSU Board of Trustees, its offers, employees and agents from any and all cost, liabilities, expenses, claims, demands, or causes of action on account of any loss or personal injury that might result from my choice not to act in accordance with the sickle cell trait testing recommendations of the NCAA and Sonoma State University Department of Intercollegiate Athletics. I DO understand that if I am selected to be a part of an SSU intercollegiate team I will be required to show proof of my sickle cell results upon submission of medical eligibility paperwork. I have read and signed this document with full knowledge of its significance. I further state that I am competent to sign this waiver. (If under 18 years of age parent/guardian signature is also required below) Athlete Signature: * If under 18 years of age I am the parent or legal guardian of the student-athlete. I have read and signed this document with full knowledge of its significance. Parent/Guardian Signature: ITEM 3

5 Seawolves Sports Medicine Physical Exam for Tryout (pg. 1 of 2) TO BE COMPLETED BY ATHLETE WITH PHYSICIAN Athlete Name: DOB: Age: Athlete Address: Phone: Emergency Contact Name: Phone: 1. Has a doctor ever denied or restricted your participation 2. Does anyone in your family have asthma? in sports for any reason? 3. Do you have an ongoing medical condition (like diabetes 4. Do you have any rashes, sores, infections, or other skin or asthma)? problems? 5. Are you currently taking any prescription or nonprescription 6. Have you been hit in the head and been confused or lost (over the counter) medicine or pills? your memory for any duration of time? 7. Do you have any allergies? 8. Have you ever had a seizure? 9. Have you ever lost consciousness during exercise or activity? 10. When exercising in the heat, do you have severe muscle cramps? 11. Have you ever lost consciousness after exercise or 12. Have you ever had numbness, tingling, or weakness in activity? your arms or legs after being hit or falling? 13. Have you ever had discomfort, pain, or pressure in your 14. Have you ever been unable to move your arms or legs chest during exercise or activity? after being hit or falling? 15. Does your heart race or skip-beats during exercise or activity? 16. Has a doctor told you that you, or someone in your family, have sickle cell trait or sickle cell disease? 17. Has a doctor ever told you that you have (check all that apply): High blood pressure High cholesterol A heart murmur A heart infection 18. Do you wear glasses, contacts, or protective eyewear ever? 19. Has your doctor ever ordered a test for your heart, e.g., 20. Have you had any problems with your eyes or vision? EKG? 21. Has anyone in your family died for no apparent reason? 22. Do you cough, wheeze, or have difficulty breathing during or after exercise or activity? 23. Has anyone in your family had a heart problem? 24. Have you ever had a head injury or concussion? 25. Has any family member or relative died of heart 26. Where you born without, or are you missing a kidney, problems or sudden death before age 50? eye, tactical, or any other organ? 27. Does anyone in your family have Marfan syndrome? 28. Do you have headaches with exercise or activity? 29. Have you ever been hospitalized? 30. Do you regularly use a brace or assistive device? 31. Have you ever had surgery? 32. Have you ever had a stress fracture? 33. Have you ever had an injury like a sprain, strain, or 34. Are you happy with your weight? tendonitis that caused you to miss practice or a game? If yes, check where below: 35. Have you ever had a fractured bone or dislocated joint? 36. Are you trying to gain or lose weight? If yes, check where below: 37. Have you ever had a bone or joint injury that required either X-rays, MRI, CT, surgery, injections, rehab, a brace, a cast, or crutches? If yes, check where below: 38. Had anyone recommended that you change your weight or eating habits? Head Neck Shoulder Upper arm Elbow Forearm 39. Do you limit or carefully control what you eat? Hand/fingers Chest Upper back Lower back Hip Thigh Knee Ankle Calf/shin Foot/toes 40. Have you had infectious mononucleosis (mono) within 41. Do you have any concerns that you would like to discuss the last month? with the doctor? Females only 42. Have you ever had a menstrual period? 43. How many periods have you had in the last 12 months? Number: 44. How old were you when you had your first menstrual period? 45. Have you ever experienced or been diagnosed with Amenorrhea? Age: Please explain all Yes answers here: TO BE COMPLETED BY ATHLETE WITH PHYSICIAN (AND PARENT/GUARDIAN IF APPLICABLE) I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct: Physician s Stamp (required) Athlete s Signature: Parent/Guardian Signature: *If Athlete is under 18* ITEM 4 1

6 Seawolves Sports Medicine Physical Exam for Tryout (pg. 2 of 2) TO BE COMPLETED BY PHYSICIAN Athlete Name: DOB: Age: Weight: Height: Sex: Female Male Pulse: BP: / Vision: R 20 / L 20 / Pupils (check one): Equal Unequal Corrected (check one): Medical Normal Abnormal Findings Date of Injury Initial Appearance Eyes/ears/nose/throat Hearing Lymph nodes Heart Murmurs Pulses Lungs Abdomen Genitourinary (males only) Skin Musculoskeletal Head/brain Neck Back/spine Shoulder/arm Elbow/forearm Wrist/hand/fingers Hip/thigh Knee Leg/ankle Foot/toes Other Cleared for athletic participation (check one): Yes, unrestricted Yes, with restrictions No Notes: Physician s Stamp (required) Name of physician (print): Date of Exam: Phone #: License #: Physician s Signature: (check one): MD DO PA NP/RN ITEM 4 2