Sports Medicine Policy and Procedures Try-Out Checklist

Transcription

1 Try-Out Checklist WHAT MEDICAL INFORMATION DO I NEED TO PROVIDE BEFORE TRYING OUT FOR AN ATHLETIC TEAM AT THE UNIVERSITY OF CONNECTICUT? The NCAA requires you to have a note signed by a licensed medical practitioner, either a doctor (MD, DO), a nurse practitioner (APRN), or a physician s assistant (PA), stating that you have been examined in the past six months and have been cleared to try out for an intercollegiate athletic team. This note can come in any form, as long as it is signed by the licensed practitioner and has their license number on it. It can come from a practitioner back home who has recently seen you or it can be done by someone locally. A sample history and physical is attached to this checklist. THIS EXACT FORM IS NOT REQUIRED. It is only there for your practitioner to use, if they so desire. The NCAA requires you to show proof of a test for sickle cell trait before you can begin trying out. You need to do one of the following: Provide evidence of a previous test. All newborns are now tested, and your doctor at home may have the results. Have the test performed. This is available at Student Health Services. You will need to have it ordered by a practitioner there. There is a fee for it. Sign a waiver declining the test. This can only be done after reading the educational material about sickle cell trait that is attached to the waiver. All of this information will need to be turned in to the coach responsible for organizing try-outs for your team. Once it has been determined that you have made the team, you will need to see one of the team physicians for a complete sports physical.

2 Medical Clearance for Try-Out DOCUMENTATION OF MEDICAL CLEARANCE TO TRY-OUT FOR INTERCOLLEGIATE ATHLETICS I have examined _ and (patient s name) document that I have found no evidence of a medical condition that would prohibit them from trying out for the following intercollegiate sports at the University of Connecticut. All sports All sports except Only the following sports of Examination (must be within 6 months of try-out): Practitioner s Name: Title: M.D. DO PA APRN Signature: Street City State Zip Phone License# State

3 Try-Out Policy Statement Name: : People Soft#: Team: DOB: Year: I do hereby release the University of Connecticut and its employees from liability due to injury or illness arising as the result of my participation as a walk-on of the above stated University of Connecticut athletic team. I also will provide proof of medical clearance to participate in athletics by a qualified health care practitioner that has been performed within 6 months prior to trying out. Within 14 days of making the team, a complete physical has to be done by a University of Connecticut Team Physician. I understand that I have to schedule an appointment at Print Name Signature Emergency Contact Information Name: Relationship: Phone Number(s):

4 Sickle Cell Fact Sheet

5 Sickle Cell Fact Sheet 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 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. Sickle Cell Trait Testing- The NCAA mandates that all student-athletes have knowledge of their sickle cell trait status, show proof of a prior test or sign a testing waiver before the student-athlete participates in any intercollegiate athletics event, including strength and conditioning sessions, practices, competitions, etc. SICKLE CELL TRAIT TESTING WAIVER I,, understand and acknowledge that the NCAA mandates that all studentathletes have knowledge of their sickle cell trait status. Additionally, I have read and fully understand the aforementioned facts and the University policy 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 University of Connecticut Department of Sports Medicine personnel. I do not wish to undergo sickle cell trait testing and I voluntarily agree to release, discharge, indemnify and hold harmless the State of Connecticut, the University, 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 non-compliance with the mandate of the NCAA. 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 Signature Parent/Guardian Signature (if under 18 years of age) Parent/Guardian Print Name Witness Sport Sport