Spring Hill College Athletic Training Department NCAA Division II Tryout

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1 Dear Parent/Guardian: Spring Hill College Athletic Training Department NCAA Division II Tryout I want to first welcome you to Spring Hill College and its athletic department; this is an exciting time for you and your student-athlete as they tryout for our athletic teams. Below, you will find five tasks that encompass the following six pages. Please read, complete, sign and return all six original documents to the address listed below. 1. Affix copies of the front and back of your primary health insurance card, along with copies of the policy holder s Driver s License and student-athlete s Driver s License. 2. Read, complete, and sign the NCAA Sickle Cell Trait Form (Choose one of the three options and sign below) 3. Complete the prospective student-athlete medical questionnaire. If you have had a surgery in the past 3 years those medical documents must be disclosed to the athletic training staff and a medical exam may be required as part of your tryout. 4. Have a Pre-Participation Physical completed by a licensed physician; that being a M.D. or D.O. within the past 6 months from the date of the tryout. Any physical that is completed by a Nurse Practitioner, Physician Assistant, or Chiropractor and returned to Spring Hill College s athletic department will not qualify as a completed athletic physical. This will slow down the clearance of the student-athlete through the sports medicine department and hinder their athletic participation. 5. Please sign the appropriate forms and return all six forms completed to the address listed below within 72 hours of your tryout. Upon delivery to Spring Hill College s sports medicine department the following documents will be reviewed and if all are completed correctly the student-athlete will then be given medical clearance for athletic activity with in Spring Hill College s athletic department for the appropriate tryout. If you have any questions through this process, please contact me at the listed contact below. Thank you for you cooperation and help in your student-athletes healthcare at Spring Hill College. Sincerely, Brian M. Gronewold, M.Ed., ATC Head Athletic Trainer Spring Hill College 4000 Dauphin St. Mobile, AL (O) (F) athletictrainer@shc.edu

2 Spring Hill College Sports Medicine Insurance Card Information Please copy the front and back of the student-athlete s current insurance card and affix it below. Front Back Please copy the POLICY holder s government-issued photo ID and affix it below. Policy holder s government-issued photo ID Please copy the STUDENT ATHLETE S government-issued photo ID and affix it below. Student athlete s government-issued photo ID

3 Spring Hill College Sports Medicine Sickle Cell Trait Information Form The NCAA recommends that all student-athletes be aware of their sickle cell status. If the student athlete does not know whether they are positive for sickle cell trait, the NCAA recommends that student athletes undergo testing to determine their status. Spring Hill College is supportive of this recommendation and requests that each student-athlete provide Sports Medicine with documentation of their sickle cell trait status. If a student opts not to provide the College with this information, he/she must sign the testing waiver below. To help you make an informed decision regarding this issue, some basic information is provided below, as well as a link to additional resources. What is 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, which affects more than 3 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 and even death due to the rapid breakdown of muscles starved of blood. More information regarding sickle cell trait and the rationale for the NCAA s recommendation that all student athletes be aware of their status may be found at How do I get tested for sickle cell trait? Spring Hill College offers sickle cell trait screening in the form of a blood test to all student-athletes. Testing can be conducted at the offices of their primary care physician or other laboratory facility of the student s choosing. If you do choose to have a sickle cell test performed, please inform your athletic trainer and one will be set up for you. If you choose to undergo testing, all costs associated will be responsible to the student-athlete.

4 Choose 1 of 3 Options Below and Sign Bottom Section Sickle Cell Trait Waiver Form I,, understand and acknowledge that the NCAA and Spring Hill College recommends that all student-athletes have knowledge of their sickle cell trait status. Additionally, I have read and fully understand the aforementioned facts 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 Spring Hill College athletic training staff. 1. By signing this option, I confirm that 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 Spring Hill College, its officers, employees and agents from any and all costs, liabilities, expenses, claims, demands, or causes of action on account of any loss or personal injury that might result from my decision not to follow the recommendation that I be aware of my sickle cell trait status and share that information with the Spring Hill College Athletic Training Department. Student-Athlete Signature: 2. By signing this option I state that I HAVE PREVIOUSLY UNDERGONE sickle cell trait testing Must attach a copy of the previous test results. Test results are usually found at your Pediatrician s office or with the County Public Health Department. Date of test: Results of testing: Yes, I HAVE sickle cell trait No, I DO NOT HAVE sickle cell trait Student-Athlete Signature: 3. By signing this waiver, I confirm that I DO WISH to undergo sickle cell trait testing as part of my preparticipation physical examination so that I may be aware of my sickle cell trait status and share that information with the Spring Hill College athletic training department. Student-Athlete Signature: I have read and signed this document with full knowledge of its significance. I further state that I am at least 19 years of age and competent to sign this waiver. Student-Athlete Signature: Parent/Guardian Signature (if S-A is under 19 years of age): Parent/Guardian Print Name:

5 Spring Hill College Sports Medicine Prospective Student-Athlete Medical Disclosure Form (Please print and use pen) NAME SPORT TODAY'S DATE BIRTHDATE / / SCHOOL CURRENTLY ENROLLED HOME STREET ADDRESS HOME CITY, STATE, ZIP CELL PHONE ( ) ADDRESS: Head / Concussion Yes No 1. Have you ever been diagnosed with a concussion? 2. If yes, how many? 3. Have you ever been hospitalized with a head injury? 4. Do you have any vision problems? 5. Do you wear glasses or contact lenses during competition? Upper Extremity Yes No 1. Have you ever had either shoulder "pop out" or "dislocate"? 2. Do you experience any grinding or popping pains in either shoulder? 3. Have you ever fractured or dislocated an elbow, forearm, wrist, hand or finger? 4. Have you ever experienced any pain throwing and/or weight lifting? Lower Extremity Yes No 1. Have you had a hip or pelvic fracture? 2. Do you experience frequent hip pain during athletic activity? 3. Have you experienced a "pulled" or strained hamstring, quad or groin? 4. Have you ever suffered a knee injury? (ligaments, cartilage, kneecap) 5. Have you ever had a knee injury which required crutch-walking or surgery? 6. Do you experience any on-going knee problems? (pain, swelling, stiffness, instability) 7. Have you ever had a foot or ankle injury that required a cast or surgery? 8. Do you experience any on-going foot or ankle problems? (pain, swelling, stiffness, instability) 9. Do you wear any type of orthotic, support or brace?

6 Spine Yes No 1. Have you ever had a strain to the neck that caused a burning sensation in either arm? 2. Has a neck problem or injury ever caused a prolonged weakness of your arm or hand? 3. Have you ever sustained a neck fracture? 4. Have you ever experienced any neck pain? 5. Have you ever experienced any mid back pain? 6. Have you ever experienced any low back pain? 7. Have you ever sustained a fracture or disc problem in the low back? 8. Have you ever had a low back problem that caused a burning sensation in either leg? 9. Have you ever experienced any back pain while weight lifting or playing your sport? Heat Illness Yes No 1. Have you ever had any trouble with dehydration? 2. Have you ever passed out in the heat? 3. Have you ever had Heat Cramps (from fluid loss because of excessive heat)? General Medical Yes No 1. Have you ever had an injury to or a problem with the spleen, liver, kidneys or reproductive system? 2. Do you have a heart murmur or other irregularity? 3. Do you experience shortness of breath, heart palpitations, dizziness or fainting, weakness or paralysis? 4. Have you ever been under treatment for hypertension, diabetes, cancer, epilepsy, asthma or any other medical condition? 5. Do you have the absence of a paired organ? (eye, ear, kidney, etc) 6. Have you received treatment or counseling for a nervous condition, personality or character disorder, emotional or substance abuse problem? 7. Females Only - Have you been under treatment for any recent or on-going gynecological problems? 8. Have you experienced any recent weight loss or gain? 9. Have you ever been diagnosed with a stress fracture? 10. Do you adhere to any specific diet regimen? 11. Do you take any vitamins, supplements, or other nutritional aids? Conditioning Status (What have you done to stay in shape?) Please explain in this section:

7 General Information 1. Indicate any injuries that have required surgery, and the surgery date: Date Date Date 2. Have you been told you should have surgery and chose not to undergo surgery? Yes No If yes, when and why? 3. Indicate any injury or other problem that will require surgery prior to athletic participation at Spring Hill College. 4. Have you ever been told by a physician that you should not participate in athletics? Yes No If yes, when and why? 5. May the Spring Hill College medical staff contact this physician? Yes No Physician's Name Phone Number Address City/State/Zip 6. List all prescription medication used in the past 12 months: Do you currently wear any supportive/protective device (brace, sleeve, support) or require taping for athletic participation? Yes No If so, please elaborate Any significant injury requiring physician's care over the past three years will require medical reports and/or physician clearance for athletic activity on file in the Athletic Training Office. By my signature, I agree that all of the preceding information is answered accurately and to the best of my knowledge. I understand that if I have fraudulently misrepresented any information regarding my medical history, institutional financial aid based on athletic ability may be reduced or canceled. Student-Athlete Signature: Parent/Legal Guardian Signature (If S-A is under 19 y.o.)

8 NCAA DIVISION II TRYOUT FORM PROSPECTIVE STUDENT-ATHLETE Student Name: UPROSPECT INFORMATION Sport: Date of Birth: Grad Date of Tryout: Eligibility Center ID#: Date Approved by Compliance: TRYOUT INFORMATION Per Bylaw , a member institution may conduct a tryout of a prospect only on its campus or at a site at which it normally conducts practice or competition beginning June 15 immediately preceding the prospective student-athlete s junior year in high school and only under the following conditions: (a) No more than one tryout per prospective student-athlete per institution per sport shall be permitted; (b) The tryout may be conducted only for high school prospective student-athlete who are enrolled in a term other than the term in which the prospective student-athlete s high school's traditional season in the sport occurs or who have completed high school eligibility in the sport; for a two-year college student, after the conclusion of the sport season or anytime, provided the student has exhausted his or her two-year college eligibility in the sport; and for a four-year college student, after the conclusion of the sport season, provided written permission to contact the prospective student-athlete (per Bylaw ) has been obtained; (c) The tryout may include tests to evaluate the prospective student-athlete s strength, speed, agility and sport skills. Except in the sports of football, ice hockey, lacrosse, the tryout may include competition. (d) Competition against the member institution's team is permissible, provided such competition occurs during the academic year and is considered a countable athletically related activity per Bylaw ; (e) The time of the tryout activities (other than the physical examination) shall be limited to the length of the institution's normal practice period in the sport but in no event shall it be longer than two hours; and (f) The institution may provide equipment and clothing on an issuance-and-retrieval basis to a prospective student-athlete during the period of the tryout. Compliance Office and Athletic Trainers will approve tryout period and participants prior to the date of the tryout. RELEASE AGREEMENT My son/daughter, as noted above is in excellent physical condition according to our family physician. I hereby release and forever discharge any and all rights and claims for damages against Spring Hill College and any and all of its employees. I further authorize Spring Hill College to act for me according to their best judgment in an emergency requiring medical attention on my son/daughter. I understand that my insurance policy will be used to cover the cost of any accidents or injuries and that Spring Hill College is not covering this tryout under its insurance policies. I understand all the regulations regarding a NCAA Division II tryout and I meet those conditions. I further understand the release statement as written above and agree to the terms. Student-Athlete: Parent or Guardian: