FRESHMEN/TRANSFER STUDENT CHECKLIST Pre Participation Questionnaire Medical Consent Form Insurance Form Please include a copy of the FRONT and BACK of your insurance card. Pre Participation Physical Form **NOTE: The NCAA requires that all pre participation physical exams must have been completed no more than 6 months prior to the student athlete s first participation (practice, competition or conditioning activities). Sickle Cell Trait Form Please make sure all forms are: 1 Filled out accurately. 2 Signed by the student athlete or a parent or guardian if athlete is under 18 years of age.
DeSales University Return by July 1 Athletic Training 2755 Station Ave. Center Valley, PA 18034-9568 (610)282-1100 ext. 1848 Fax: (610)282-1404 Intercollegiate Athletic Pre-Participation Questionnaire Freshman/Transfer/Walk-on Sport(s): Social Security #: Date of Birth: Local or Cell Phone Number: Expected Date of Graduation: _ Name Parent/Guardian Name Family Physician Address Parent/Guardian Telephone # Physician Address City Emergency Contact Person City State Zip State Zip Emergency Phone # Family Physician Telephone # 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, i.e. diabetes? Is there loss or seriously impaired function of any organ? 2. Have you ever been hospitalized overnight? Have you ever had surgery? 3. Are you currently taking any prescription or non-prescription (over-the-counter) medications? Do you use an inhaler? Have you ever taken any supplements or vitamins to help you gain or lose weight or improve performance? Have you ever been diagnosed with an eating disorder? 4. Do you have any allergies, i.e. environmental, food, medicine, 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 had high blood pressure? Have you had high cholesterol? Have you ever been told you have a heart murmur? Have you ever had racing of your heart or skipped heart beats? Has any relative died of heart problems or sudden death before age 50? Have you had a severe viral infection, i.e. myocarditis, mononucleosis within the last month? Has a physician ever denied or restricted your sports participation for any heart problems? 6. Have you ever had a head injury or concussion? Have you ever been knocked out, become unconscious, or lost your memory? Have you ever become disorientated or had a loss of awareness during participation? Have you ever had a seizure? Do you have frequent or severe headaches? Have you ever had numbness or tingling in your arms, hands, legs, or feet? Have you ever had a burner, stinger, or pinched nerve? 7. Have you ever had heat or muscle cramps? Have you ever become ill (passed out or dizzy) from exercising in the heat?
8. Do you cough, wheeze or have trouble breathing during or after exercise? Do you have asthma? Do you have seasonal allergies that require medical treatment? 9. Do you use any special protective or corrective equipment or devices, i.e. knee braces, mouth guard, hearing aid, etc? 10. Have you had any problems with your eyes or vision? Do you wear glasses, contacts, or protective eyewear? Have you had any problems with your ears? Have you broken/fractured any bones or dislocated any joints? Have you ever had a sprain, strain, or swelling after an injury? Have you had any other problems with pain or swelling in muscles, tendons, bones, or joints? 11. When was your last tetanus shot?_ FEMALES ONLY When was your first menstrual period? When was your last menstrual period? Time between start of one period and the start of the next? How many periods have you had in the last year? Have you had any menstrual problems that required treatment by a doctor and what did the treatment consist of? EXPLAIN ALL YES ANSWERS HERE: DeSales University student-athletes have the responsibility to truthfully and fully disclose his/her medical history and to report any changes in his/her health to the certified athletic trainer. Athlete s signature Date
DeSales University Medical Consent Forms Please read the following consent forms carefully: If you are under 18 years of age, your parents must also sign. The basic content of each is: Part I. Medical Consent: Allows DSU certified athletic trainers and DSU affiliated physicians to treat any injury or illness incurred by you while at DeSales University. Part II. Release of Information: Allows those listed to release and/or receive information concerning your injuries or illnesses to insurance carriers, your parents, your coaches, DeSales University s Health Center Staff, NCAA research directors, and /or from medical personnel and facilities, to DSU. Part III. Shared Responsibility: Provides information to you concerning certain inherent risks involved in participating in intercollegiate athletics and that you are willing to assume responsibility for such risks. MEDICAL CONSENT-Part I I hereby grant permission to the DeSales University (DSU) affiliated physicians to provide me with any medical care or surgical care that they deem reasonably necessary to my health and wellbeing as a result of injuries or other medical conditions occurring as the result of or during DSU athletic activities. I further authorize the certified athletic trainers at DSU who are under the direction and guidance of the DSU affiliated physicians to provide me with any preventive, first-aid, rehabilitative or emergency treatment they deem reasonably necessary to my health and wellbeing as a result of injuries or other medical conditions occurring as the result of or during DSU athletic activities. If reasonably necessary to provide the care described in the preceding two paragraphs, I grant permission to DSU officials to hospitalization at an accredited hospital. ATHLETE S SIGNATURE Signature may be that of athlete 18 years of age; if under 18, signature of parent or guardian is required. I hereby grant permission on behalf of my minor son or daughter or my ward. PARENT OR GUARDIAN S SIGNATURE AUTHORIZATION FOR RELEASE OF INFORMATION-Part II A. I hereby authorize DeSales University athletic administration, certified athletic trainers, physicians affiliated with DSU, and coaches to release medical information to my parents, insurance carriers, and NCAA research directors any information concerning illness or injury relative to my past, present, or future participation in athletics at DeSales University. B. I hereby authorize the DeSales University s Health Center Staff to release a copy of my Medical History and Physical Examination Form to the DSU certified athletic trainers. I acknowledge that it is my responsibility to report any change in my health status to the certified athletic training staff throughout the entire academic school year. I also authorize any medical facility, physician, or medical personnel who has attended me to disclose when requested by DSU, any and all information regarding my illness or injury, medical history, consultation, diagnostic tests, treatment, recommendation, and copies of all hospital or medical records. A photo copy of this authorization shall be considered valid and effective as the original. ATHLETE S SIGNATURE Signature may be that of athlete 18 years of age; if under 18, signature of parent or guardian is required. I hereby grant permission on behalf of my minor son or daughter or my ward. PARENT OR GUARDIAN S SIGNATURE SHARED RESPONSIBILITY FOR SPORTS SAFETY-Part III The responsibility for sport safety must be shared by all. Included in this group should be administrators, coaches, physicians, certified athletic trainers, and student-athletes. I, the undersigned, am aware that there is a certain risk of injury involved in my participation in Intercollegiate Athletics at DeSales University. I understand that my signature does not relieve DeSales University of it s responsibilities to me. This document is intended to make me aware of my responsibility in preventing potential injuries, complying with the treatment plan of the DSU athletic medical staff, and that there is risk of injury. I understand that this includes the risk of spinal cord and brain injury that may result in paralysis and the possibility of other permanent injury or death. I have read the above shared responsibility statement. I acknowledge the fact that these risks exist and I am willing to assume responsibility for such risks while participating at DeSales University. ATHLETE S SIGNATURE Signature may be that of athlete 18 years of age; if under 18, signature of parent or guardian is required. I hereby grant permission on behalf of my minor son or daughter or my ward. PARENT OR GUARDIAN S SIGNATURE
DeSales University INTERCOLLEGIATE ATHLETE INSURANCE INFORMATION The following information MUST be fully completed, signed and returned prior to clearance for intercollegiate athletic participation. Proof of insurance is REQUIRED for participation. A photocopy of this authorization will be deemed as effective and valid as the original. Athlete s Name SSN_ Date of Birth Local Address_ Local or Cell PhoneSport_ FATHER S/ GUARDIAN S INFORMATION MOTHER S/GUARDIAN S INFORMATION Name Address City State Home Phone Zip_ BirthdateSSN Employer Address City State Work PhoneZip_ Name of Medical Insurance Address CityState Phone #Zip_ Group Policy Number ID Number _ Is the athlete covered under the above policy? Is the above policy a PPO? Name_ Address City_State Home Phone_Zip_ Birthdate_SSN Employer Address City_State Work Phone_Zip_ Name of Medical Insurance Address City_State Phone #Zip_ Group Policy Number ID Number _ Is the above policy an HMO? Is pre-certification required? I hereby certify that the answers provided are true, complete, and correct to the best of my knowledge. You must include a photocopy of the front and back of your insurance card Athlete s Signature Parent/Guardian Signature (if under 18) Date Date
DeSales University Pre-Participation Physical Examination Athlete s Name Date of Examination Height Weight Brachial Blood Pressure_ Pulse Vision R uncorrected corrected L uncorrected corrected Heart Heart Auscultation Supine Heart Auscultation Standing Lungs Pulses (include femoral) Skin Abdominal Genitalia Musculoskeletal Neck Shoulder Elbow Wrist Hand Back Hip Knee Ankle Foot Vision/Hearing Sickle Cell Trait/Disease Normal Findings Abnormal Findings Cleared for intercollegiate athletic participation Cleared after completing evaluation/rehabilitation for: Not cleared for: Collision Contact Non-contact Physician s SignatureDate Name of Physician Telephone # Address City, State, Zip
DeSales University Athletics Sickle Cell Trait Form Sickle Cell Trait Testing The NCAA mandates that all student athletes have knowledge of their sickle cell trait status. Student athletes MUST do one of the following: show proof of a prior test with results; have a blood test to check for sickle cell trait; or sign a testing waiver declining options 1 and 2. Whichever option is chosen, it must be completed prior to participation in any intercollegiate athletic events, including strength and conditioning sessions, practices, competitions, etc. Athletes who are positive for the trait ARE PERMITTED to participate in intercollegiate athletics. Documentation is provided for: Test administered as a newborn. Proof of test with results are attached. Date: Most states require testing at birth, check with your hospital or pediatrician Recently had blood test to screen for sickle cell trait. Results are attached. Date: Signing testing waiver below SICKLE CELL TESTING WAIVER By signing this waiver I understand and acknowledge that the NCAA mandates that all student athletes have knowledge of their sickle cell trait status. Additionally, I certify that I have read and fully understand the facts provided below and I have had the opportunity to review the NCAA website for further 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 the DeSales University Athletic Training Department. I do not wish to undergo sickle cell trait testing and I voluntarily agree to release, discharge, indemnify and hold harmless DeSales University, its officers, employees, agents and their successors and assigns from any and all costs, claims, damages or expenses, including attorney s fees, arising from any loss or personal injury that might result from my refusal to be tested. 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 s Signature Student Athlete s Print Name Date SPORT(s): Parent/Guardian s Signature (if under 18 years of age) Parent/Guardian s Print Name Date About Sickle Cell Trait Sickle cell trait is not a disease. Sickle cell trait is an inherited condition affecting the oxygen carrying substance, hemoglobin, in the red blood cells. You are born with sickle cell trait; it cannot be developed over time or contracted like a disease. Although Sickle cell trait occurs most commonly in African Americans and those of Mediterranean, Middle Eastern, Indian, Caribbean, and South and Central American ancestry, persons of all races and ethnicities may test positive for this condition. Those with sickle cell trait usually have no symptoms or any significant health problems. However, sometimes during very intense, sustained physical activity, as can occur with collegiate sports, certain dangerous conditions can develop in those with sickle cell trait, leading to blood vessel and organ (kidneys, muscles, heart) damage that can cause sudden collapse and death. Some of the settings in which this can occur include timed runs, all out exertion of any type for 2 to 3 continuous minutes without a rest period, intense drills and other bursts of exercise after doing prolonged conditioning training. Extreme heat and dehydration increase the risks. (NCAA: A Fact Sheet for Coaches, Sickle Cell Trait, http://web1.ncaa.org/web_files/health_safety/sicklecelltraitforcoaches.pdf) More information and resources regarding sickle cell trait and the NCAA s mandate for sickle cell trait testing can be found at the NCAA web site resource pages regarding the sickle cell trait, accessible at: www.ncaa.org/health safety.