The University of Michigan
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1 Tryout Directions and Information: The University of Michigan This packet contains the following forms that must be completed before your tryout can begin: Tryout clearance form You only need to fill out the top portion of this form and indicate your status (i.e. freshman, upperclassmen, or transfer). *Please note: you DO NOT need to register with the NCAA Eligibility Center until you are added to a team. If you have questions regarding this, please contact the compliance office. Steps 1-3 will be completed by the Athletic Department: This requires you to obtain signatures from the coach, the compliance office, and the athletic trainer for the sport you are trying out for Steps 4&5 only need to be completed if added to a team Personal contact information sheet Liability waiver form Sickle Cell Trait information sheet and waiver form Please note that if you are under the age of 18, your parent or guardian must also sign this form You will also be required to submit the following documents before your tryout can begin: A pre-participation exam completed and signed by a physician stating that you are cleared for participation in sports Your physical must be dated within the past 6 months If you need a new physical exam, you can contact UHS at (734) for an appointment. Other establishments offer physical exams but have an associated cost. A copy of the front and back of your personal insurance card Once the compliance office and the coach sign off of the Try-out clearance form, please submit this completed packet to the Athletic Trainer for the sport that you are trying out for. Please be aware that all documents listed above must be fully completed in order for your try-out to begin.
2 UNIVERSITY OF MICHIGAN DEPARTMENT OF ATHLETICS Tryout Clearance Form Print Name: of Birth: / / UM ID: Sport: High School Graduation Month/Year: Please indicate your status: NCAA Rules require you to register with the NCAA Eligibility Center in order to compete. $70 Domestic/$120 International at I have already registered with the NCAA Eligibility Center YES NO I am a freshman I am a continuing UM student * Please list date of initial full-time enrollment at UM (Month/Year) I am a transfer student School(s) Previously Attended s of Attendance I agree to comply with all rules and regulations set forth by the University of Michigan, Big 10 Conference and NCAA. I understand that I will not be allowed to practice until I have been approved by each office in the clearance process, and that I MUST REMAIN IN 12 CREDIT HOURS FOR THE DURATION OF MY TRYOUT. Student-Athlete Signature: NOTE: STEPS 1 through 3 must be completed PRIOR to the student-athlete trying out during practice. Step 1 Receive the signature of the coach I agree to allow this student to practice but not compete until a determination of eligibility is made. Please indicate the recruiting status of the student: RECRUITED NOT RECRUITED Tryout Start Coach s Signature: (IF NO DATE INDICATED, TRYOUT WILL NOT BE APPROVED) Step 2 Signature from the Compliance Services Office, Director of Eligibility It has been determined that the student is enrolled as a full-time student, 12 credit hours, at the University of Michigan. Credit Hrs Enrolled: GPA Check CSO Signature: Step 3 Obtain pre-participation approval from Athletic Medicine The student-athlete has completed and signed all required medical documents: Pre- participation physical within the last six months Sickle Cell Trait Waiver Copy of insurance card (front and back) Emergency contact information Liability waiver Certified Athletic Trainer:
3 If adding the student-athlete to the roster, complete Steps 4 and 5. Step 4 Complete Compliance Forms within 14 days of tryout start date If 14 days have passed since the student-athlete began his or her tryout, he or she may not continue to practice until all compliance forms have been completed. CSO Signature: I want to add the student-athlete to my roster. Coach s Signature: Step 5 Obtain final approval from Athletic Medicine The student-athlete has completed the remaining medical requirements to participate with the team: Completed physical exam by team physicians Updated insurance information (if needed) Option to keep sickle cell waiver or be tested Completed Education Seminar and signed forms (Drug Testing/Big Ten Injury Reporting forms) Neurocognitive testing for applicable sport Yes No Certified Athletic Trainer: Return to the Compliance Services Office once complete. NOTE: Once this form is complete, the student-athlete is cleared to practice, but NOT to compete until he or she receives final eligibility certification from the CSO.
4 University of Michigan ATHLETIC MEDICINE PERSONAL CONTACT INFORMATION NAME: SPORT: PHONE: CURRENT ADDRESS: UMID: DATE OF BIRTH: EMERGENCY CONTACT INFORMATION NAME: PHONE: RELATION: CELL PHONE: ADDRESS: MEDICAL ALERTS Do you have any known allergies: YES / NO Please List (if Yes): Are you currently taking any medications: YES /NO Please List (if Yes):
5 WAIVER FORM: Non-rostered Walk-on Athletes I,, confirm that I have submitted a copy of (please print name) a physical examination which was completed by a physician within the past six (6) months, stating that I am in good physical health. I fully understand that I am trying out for (sport) on my own free will and that I am responsible for any injuries incurred during such tryouts. I am clearly aware that there are risks associated with this participation and I assume these risks. I further understand that The University of Michigan Athletic Department will not pay for any medical care that is needed as a result of this participation and the Athletic Medicine staff will be responsible only for providing first aid care and referral to an outside physician if deemed necessary. Signature of Athlete
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7 Sickle Cell Trait Testing 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 not a disease (in general, people with this are healthy). 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 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. The University of Michigan Department of Intercollegiate Athletics offers sickle cell trait screening in the form of a blood test to all student-athletes as part of the pre-participation physical examination process. Testing will be conducted at the University of Michigan University Health Center Laboratory and/or other designated laboratory facility and results will be reported to a University of Michigan Team Physician. SICKLE CELL TRAIT TESTING WAIVER I,, understand and acknowledge that the NCAA and the University of Student-Athlete Print Name Michigan Department of Intercollegiate Athletics 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. Recognizing that my true physical condition is dependent upon an accurate medical history and 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 Michigan Sports Medicine 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 the State of Michigan, the University, 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 non-compliance with the mandate of the NCAA and the University of Michigan Department of Intercollegiate Athletics. 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 Sport UMID# Parent/Guardian Signature (if under 18 years of age) Parent/Guardian Print Name Witness
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