Radford Athletic Department Tryout Clearance Form

Transcription

1 Radford Athletic Department Tryout Clearance Form This form is to be utilized for all student-athletes who are not on the official team roster after reporting for the fall team meetings. The student-athlete will not be allowed to receive equipment or practice until he or she has been approved for practice through this process. Student s Name: _ Radford ID#: of Birth: _ Sport: Type of Student: Freshman Continuing Transfer International I understand that I will not be allowed to practice until I have been approved by each office in the clearance process and issued an approval for practice. _ Student s Signature Radford STEP 1: Completed by the Sports Medicine Office The student-athlete has completed and submitted all proper documentation (physical exam, health insurance and sickle cell testing) and has been cleared by Sports Medicine to participate in intercollegiate athletics. Yes No Signature of Certified Athletic Trainer STEP 2: Completed by Student, checked by Compliance and/or athletic department staff member First Term of Full Time Enrollment: First Term of Full-Time Enrollment at Radford University: Declared Major? Yes No Enrolled Full Time for Current Term: Yes No STEP 3: Completed by the Compliance Office Status with NCAA Eligibility Center: Qualifier Non-Qualifier Pending / Not Registered Certified to Practice: Yes No 14-Day Temporary Practice Period: to _ Signature of Compliance Office

2 ACKNOWLEDGEMENT, WAIVER AND RELEASE OF LIABILITY (INCLUDING INDEMNITY) FOR ATHLETIC TRY-OUTS THIS AFFECTS YOUR LEGAL RIGHTS PLEASE READ CAREFULLY BEFORE SIGNING I,, fully understand and appreciate the physical risks to me while engaging in athletic try-outs for the sport of. Those risks include, but are not limited to physical injuries that occur in connection with practice, weight/ strength training, conditioning, open gym, and open/ players practice. I also understand that it is my responsibility to have on file with the Sports Medicine staff in the Radford University Sports Medicine Department the following items before I am allowed to participate in a try-out activity. Copy of Current and Valid Health Insurance Card(s)- front and back Physical by a U.S. Licensed M.D. or D.O. within the last 6 months (may be completed at the Radford University Student Health Center for $10**) Disregard the statement that it must be completed by an RU Physician. Authorization for release of Personal Health Information Documented Sickle Cell Status (you may obtain this blood test at the RU Health Center for $10** ** To make an appointment at the RU Health Center, please call and tell them that you are an athletic tryout and need to schedule a physical and sickle cell screen (total $20)- you will need the results before you try out. I certify that I am in good physical health, that I am physically able to perform all athletic activities associated with the try-out, and that I have no known physical conditions which could be worsened or aggravated by my participation, except as follows: I understand that the Radford University Sports Medicine staff has the right to deny my participation in this try-out due to a medical condition found or detailed in my physical. Preexisting medical conditions may have to be corrected prior to participation in the try-out. I understand that all costs associated with any tests, consultations and medical procedures associated with seeking approval for participation in the try-out are my responsibility or the

3 responsibility of my parent(s)/legal guardian(s). I understand that by signing below, I am acknowledging that neither the University nor its insurance carriers will provide insurance coverage to me for any loss or damage whatsoever that I sustain in connection with athletic tryouts. In consideration of the Radford University Athletic Department permitting me to participate in the athletic tryouts for the sport of team/program and by signing below, I, for myself, my parents, children, heirs, beneficiaries, personal representatives and assigns and for all persons and entities having any claim arising through me, do hereby waive, release, and discharge Radford University and the Commonwealth of Virginia, their officers, agents, representatives and employees (collectively, Released Entities ) from and against any and all liability, claim or action whatsoever arising out of or related to any injury (including death), loss or damage that I may sustain in any way connected with my participation in the athletic try-outs for the sport of, including, but not limited to practice, weight/strength training, conditioning, open gym, and open/ players practice and whether or not caused by the negligence of any of the Released Parties. I agree not to sue Released Entities for any such injury (including death), loss or damage, and I also agree to indemnify and hold Released Entities harmless from any such injury (including death), loss or damage, including court costs and attorneys fees. I am either eighteen (18) years of age or older or my parents or legal guardians have joined me in signing this instrument. Tryout Signature Printed Name Parents/ Legal Guardians (if tryout is under 18) Signature Printed Name Signature Printed Name

4 Name Sport Student Must Answer All Questions Prior to Exam Has anyone in your immediate family had any of the following problems? Tuberculosis No Yes Who? Diabetes No Yes Who? Kidney Disease No Yes Who? High Blood Pressure No Yes Who? Cancer No Yes Who? Epilepsy No Yes Who? Heart Attack/Heart Disease No Yes Who? Stroke No Yes Who? Sudden Death No Yes Who? (Cause) (Age) Your Personal Medical History (Check yes or no and explain all yes answers in the spaces following the list.) Scarlet Fever No Yes Measles No Yes Whooping Cough No Yes Chickenpox No Yes Diabetes No Yes Thyroid Disease No Yes Rheumatic Fever No Yes Stomach Problems No Yes Pneumonia No Yes Fatigue No Yes Depression/Anxiety No Yes Mumps No Yes Mono No Yes Kidney Infection No Yes Epilepsy No Yes Hypertension No Yes Heart Murmur No Yes Asthma No Yes Fainting Spells No Yes Hepatitis No Yes Migraines No Yes Hernia No Yes Blood in Urine No Yes Protein in Urine No Yes Anemia No Yes Abnormal Bruising No Yes Sickle-Cell Disease No Yes Hearing Problems No Yes Heart Disease No Yes Abnormal Heart Beat No Yes Undescended Testicle No Yes Scoliosis No Yes Suicidal Thoughts No Yes Menstrual Problems No Yes Explain Yes answers below. Circle any questions to which you don t know the answers YES NO 1. Have you had a medical illness or injury since your last check up or sports physical? Do you have an ongoing or chronic illness? 2. Have you ever been hospitalized overnight? Have you ever had surgery? 3. Are you currently taking any prescription, non-prescription (over-the-counter) medications, pills or using an inhaler? Have you ever taken any supplements or vitamins to help you gain or lose weight or improve your performance? 4. Do you have any allergies (for example, to pollen, medicine, food, or stinging insects)? Have you ever had a rash or hives develop during or after exercise? 5. Have you ever passed out during or after exercise? Have you ever been dizzy during or after exercise? Have you ever had chest pain during or after exercise? Do you tire more quickly than your friends during exercise? Have you ever had a racing of your heart or skipped heartbeats? Have you ever had high blood pressure or high cholesterol? Have you ever been told that you have a heart murmur? Have you had a severe viral infection (for example, myocarditis or monocucleosis) within the last month? Has a physician ever denied or restricted your participation in sports for any heart problems? 6. Have you ever been diagnosed with a concussion? How many concussions have you had (list date of most recent) Have you every suffered from post-concussive syndrome? Have you ever been knocked unconscious? 7. Do you have any current skin problems? (example: itching, rashes, acne, warts, fungus or blisters) 8.Have you ever had a seizure? Do you have frequent or severe headaches? Have you had numbness/tingling in arms, hands, legs or feet? Have you ever had a stinger, burner or pinched nerve? 9. Have you ever become ill/dizzy from exercising in the heat? 10.Do you cough, wheeze, or have trouble breathing during or after activity? Do you have asthma? Do you have seasonal allergies requiring medical treatment? YES NO 11. Do you use any special protective or corrective equipment for your sport? (for example, knee brace, foot orthotics, retainer for teeth, hearing aid) 12. Have you had any problems with your eyes or vision? Do you wear glasses or contacts? 13. Have you ever had a sprain, strain, or swelling after injury? Have you broken, fractured any bones, dislocated any joints? 14. Have you had any other problems with pain or swelling in muscles, tendons, bones or joints? If yes, check appropriate box and explain below. Head Chest Hand Thigh Ankle Neck Shoulder Finger Knee Foot Back Wrist Hip Shin/Calf Toes 15. Are you happy with your weight now? 16. Do you feel stressed out? 17. I often have trouble sleeping. 18. I wish I had more energy most days of the week. 19. I think about things over and over. 20. I feel anxious and nervous much of the time. 21. I often feel sad or depressed. 22. I struggle with being confident. 23. I don t feel hopeful about the future. 24. I have a hard time managing my emotions (frustration, anger, impatience) 25. I have feelings of hurting myself or others. Females only: 1. When was your first menstrual period? 2. When was your most recent menstrual period? 3. How much time do you usually have from the start of one period to the start of another? 4. How many periods have you had in the last year? 5. What was the longest time between periods in the last year? Please explain all Yes answers below.

5 Name Sport Radford University Athletics Pre-Participation Physical Form (New Student) Name Sport(s) DOB Age HT _ WT _ BMI _ BP (Brachial/Seated) / ( / ) Pulse _ Glasses: Yes No Contact Lenses: Yes No Vision: R: 20/ L: 20/ Both: 20/ History of Asthma: Yes No If Yes: Peak Flow Trial 1, Trial 2, Trial 3, Highest Peak Flow MEDICAL EXAM Norm Abnormal (Explain) MUSC/SKEL EXAM Norm Abnormal (Explain) Ears Neck Eyes Shoulders Mouth/Teeth Elbows -TMJ -Gums/Tongue Nose Hands Lymph Nodes Wrists Thyroid Hips Lungs Knees Cardiac Quad/Hamstring Include precordial auscultation, femoral pulse and Marfan Screen Ankle/Foot Abdomen Back/Spine Genitalia/Male Toe/Heel Walk Hernia Duck Walk Skin/Scars Comments Neuro List and give dates of any serious injuries or illnesses _ List any operations and dates Describe any emotional disturbances or adjustment problems Is there loss or seriously impaired function of any paired organ? No Yes If Yes: Is the patient now under treatment for any medical or emotional condition? No Yes If Yes: List any medications the patient is currently taking, including dosage and scheduled administration: Labwork Indicated: No Yes Sickle Dex: Negative Positive Needs Testing Waiver EKG/ECHO Indicated: No Yes Normal Abnormal CLEARED for (list sport/activity): CLEARED after completing eval/rehab for: NOT CLEARED FOR ANY SPORT PARTICIPATION due to: MD/DO Signature: of Exam: Printed Name of MD/DO: To be reviewed and completed by a Radford University Physician CLEARED CLEARED after NOT CLEARED _ RU Athletics Physician Signature Printed Name Terms Information on this form may be necessary in the event of an emergency. Failure to provide this information may result in delay or difficulty administering medical care. All omissions or incomplete information on this form are the responsibility of the student and his/her health care provider. This completed form must be on file with the Radford University Athletic Training Department prior to any participation in intercollegiate athletics at Radford University. I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct and that the attending practitioner, in case of emergency, may administer necessary medical treatment. In addition, I understand that my records will be destroyed 5 or 10 years after completion of athletic participation Student-Athlete Signature

6 Sports Medicine Authorization for Release of Information This is to certify that I,, RUID#, DOB _ grant permission to Radford University Sports Medicine to release and/or receive the information noted below from my medical records to and/or from: Medical providers to whom I am referred or by whom I have received medical care Any applicable insurance companies for the purpose of processing claims My parents/guardians Myself My Coaches University Administration Media representatives X_ All of the above Information to be released/received: All medical records to include all chart entries, diagnoses, test results, and reports All medical records except All medical records related to the visits on the following dates _ All records related to the following diagnosis/symptoms Psychiatric records Itemized bill* (includes diagnosis and itemized costs for service) Progress notes and diagnosis only* Test results only* Consultant reports only* Diagnosis only* X_ All of the above *Specify the dates, notes, results, reports, and/or diagnoses to be released/received: *If at any time I wish to no longer grant this release I may do so in writing to the Sports Medicine Department at any time. Signed: : _Witness: Radford University Sports Medicine P.O. Box 6913 Radford, VA p f

7 SICKLE CELL TESTING ACKNOWLEDGEMENT FORM About Sickle Cell Trait: Sickle cell trait is an inherited condition of the oxygen-carrying protein, hemoglobin, in the red blood cells. Approximately one in every 12 African-Americans has sickle cell trait (compared to approximately one in 2,000 to 12,000 white Americans). The gene for sickle cell trait is also present in individuals of Mediterranean, Middle Eastern, Indian, Caribbean and South / Central American ancestry. SCT 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 sickle shape), which can accumulate in the bloodstream and logjam vessels, leading to collapse from the rapid breakdown of muscles starved of blood and oxygen. Over a seven year span, nine athletes participating in NCAA sports died as a complication of sickle cell trait. Sickle Cell Trait Screening: The NCAA mandates that all NCAA student-athletes 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 newborns in the US are required to be screened for sickle cell and those records are kept on file. The Radford University Sports Medicine Department offers sickle cell trait screening in the form of a blood test to all student-athletes as part of the pre-participation examination process, however, please see the following statement. FALL SPORTS: It is required that new student-athletes participating in the fall sports of volleyball, soccer and cross country complete the steps to confirm their sickle cell trait status before reporting to campus in August to avoid delays in clearance for participation due to the turnaround time of the testing (minimum of 24 hours). Printed Name of Student Athlete Sport _ SSN (last 4 digits) I have been tested prior to arriving at Radford University and have provided the necessary documentation to satisfy the NCAA regulations (please attach the lab report). Test // Result I have been tested for sickle cell trait and I am awaiting the results from my physician (to be returned at a later date). I agree to screening for sickle cell trait upon arrival at Radford University. Test // Result SICKLE CELL TRAIT ACKNOWLEDGEMENT: Please read thoughtfully and carefully before signing. I understand and acknowledge that the NCAA and the Radford University Athletic Department mandate 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. I have had all questions that I may have regarding sickle cell trait and disease answered to my satisfaction. Student Athlete Signature Parent/Guardian Signature (if SA is under 18) Witness