Wagner College Sports Medicine 1 Campus Road ٠ Staten Island, NY 10301 Phone: (718) 390-3302 ٠ Fax: (718) 390-3302 Dear Parents/Guardians of Wagner College Athletes, We are pleased to have your child/dependent as a member of one of our fine athletic teams. We are hopeful that he/she will find success and enjoyment in both athletics and academics while here at Wagner College. The enclosed packet contains forms that will be required to be completed before your child/dependent will be allowed to participate in intercollegiate athletics here at Wagner College. The purpose of these forms is to ensure that your child/dependent is fit to participate in intercollegiate athletics. *NOTE: These forms are separate from the forms required by the Center for Health and Wellness. Enclosed for your convenience is a checklist to help ensure that all items are completed. Completed forms may be sent via mail, scanned and email, or fax to the address listed below. WAGNER COLLEGE DEPARTMENT OF SPORTS MEDICINE MUST RECEIVE ALL FORMS NO LATER THAN JULY 15 th ! If you have any questions concerning the enclosed documentation, please contact me at at (718) 390-3220 or via email at [email protected]. Respectfully, Alexander Lipcius, MS, ATC Head Athletic Trainer Wagner College 1 Campus Road Staten Island, NY 10301 718-390-3220 (office) 718-390-3302 (fax) [email protected]
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WAGNER COLLEGE DEPARTMENT OF SPORTS MEDICINE … · Wagner College Sports Medicine 1 Campus Road ٠ Staten Island, NY 10301 Phone: (718) 390-3220 ٠ Fax (718) 390-3302 MEDICAL FORM
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*******************************************************************************************GENERALINFORMATIONListanyallergiestomedications: Listanymedicationstakenonaregularbasisandexplainwhy AreyoucurrentlybeingtreatedforAttentionDeficit/HyperactivityDisorder(ADHD)? YES NODoyouwearcontactlensesonaregularbasis? YES NO IfYES,pleasecircle: Hard SoftTheinformationthatIhaveprovidediscompleteandcorrecttothebestofmyknowledge.Student’sSignature: Date: Parent/Guardian’sSignature: Date: (Requiredifstudent-athleteisunder18yearsofage)
Reviewed:May,2009
NewStudent-AthleteMedicalHistorySurvey
Name Sport Date
StudentID DOB Phone Thefollowingisarecordofyourpersonalmedicalhistory.Youarerequiredtoprovideaccurateinformationwithregardtoallquestions.ThisformwillbekeptonfileintheSportsMedicineOffice,andwillremainstrictlyconfidential.IGeneralHealth:
Iacknowledgethatalloftheinformationthathasbeenprovidedisaccurateandcompletetothebestofmyknowledge.Therehasbeennoattempttowithholdanypertinentinformationthatmayadverselyaffectmyhealthandperformanceasastudent-athlete. SignatureofStudent-Athlete Date SignatureofParent/Guardian(ifStudent-Athleteisaminor) Date
Iunderstandthatthereisaninherentriskofinjuryassociatedwithparticipationofintercollegiateathletics.Iunderstandthatthisinjurymayresultseriousphysicalinjury;temporaryorpermanentdisability;death;seriousneckandspinalinjuriesthatmayresultincompleteorpartialparalysis;braindamage;seriousinjurytovirtuallyallinternalorgans;seriousinjurytovirtuallyallbones,joints,ligaments,muscles,tendons,andotheraspectsofthemusculoskeletalsystem;andseriousinjuryorimpairmenttootheraspectsofthebody.Intheeventthatthereisaneedforroutineoremergencymedicalcarethatistheresultofanathleticinjuryand/orillness,IgivepermissiontotheWagnerCollegeteamphysicians,athletictrainingstaffandassociatedmedicalprofessionals,toadministertreatmentasdeemednecessary. Student-AthleteName(print) Date SignatureofStudent-Athlete NameofParent/Guardian(requiredifunder18) Date SignatureofParent/Guardian(requiredifunder18) AdditionalInformation:(Ifnecessary)
Iauthorizethephysicians,athletictrainers,sportsmedicinestaffandotherhealthcarepersonnelrepresentingWagnerCollegetoreleaseinformationregardingthestudent-athlete’sprotectedhealthinformationandrelatedinformationregardinganyinjuryorillnessduringthestudent-athlete’strainingforandparticipationinathleticsatWagnerCollege.Ifurtherunderstandthatitisatmyrequesttocomplywiththerequirementsoftheschoolandthereleaseofprotectedhealthinformationtoacoach,athleticdirectororschoolofficialinconnectionwithparticipation in intercollegiateathletics. Thisprotectedhealth informationmayconcern thestudent-athlete’smedical status, medical condition, injuries, prognosis, diagnosis, athletic participation status, and relatedpersonally identifiablehealth information. Thisprotectedhealth informationmaybereleasedtootherhealthcare providers, hospital, and/or medical clinics and laboratories, athletic coaches, medical insurancecoordinators,athleticand/orschooladministratorsassociatedwithWagnerCollege. Student-Athlete’sName(Print) Date SignatureofStudent-Athlete Parent/Guardian’sName(ifStudent-Athleteisaminor) Date SignatureofParent/Guardian(ifStudent-Athleteisaminor)
• ReadtheattachedSickleCellTraitFactsheetfromtheNCAAformoreinformation.Ihavereadandunderstandtheabovematerial,andIhavereceived,read,andunderstandtheNCAASickleCellTraitFactSheet. Signature Date SignatureofParent/Guardian(ifStudent-Athleteisaminor) Date
WAIVERI,____________________________understandandacknowledgethattheNCAAandWagnerCollegeDepartmentof(PrintName)Athleticsrecommendsthatallstudent-athleteshaveknowledgeoftheirsicklecelltraitstatus.Additionally,Ihavereadandfullyunderstandtheaforementionedfactsaboutsicklecelltraittesting.Ichoosenottoreceiveascreeningtestforthesicklecelltrait.IacknowledgetheriskofparticipatinginWagnerathleticswithoutbeingtestedforthesicklecelltrait.Iassumeallresponsibilityforanyconditionsthatariseduetosicklecellandparticipationinathleticsinthefuture.________________________________________________ _____________________SignatureofStudent-Athlete Date________________________________________________ _____________________SignatureofParent/Guardian(ifunder18) Date
IagreethatifIwithholdthefactthatIhavesustainedaconcussionfromWagnerCollegeSportsMedicineIagreetoassumealltherisksandresponsibilitiessurroundinganysubsequentorrelatedinjuryorharm;andinadvanceherebyrelease,waive,foreverdischarge,andcovenantnottosueWagnerCollege,theofficers,agents,teamphysicians,andaffiliates,andemployeesofWagnerCollege(allofwhomarecollectivelycalledWagnerCollege),fromandagainstanyandallliabilityforanyharm,injury,damage,claims,demands,actions,causesofaction,costs,andexpensesofanynaturethatImanyhaveorthatmayhereafteraccruetome,arisingoutoforrelatedtoanyloss,damage,orinjury,includingbutnotlimitedtosufferinganddeath,thatmaybesustainedbyme,duetomyfailuretoreport.Itismyexpressintentthatthisassumptionofrisk,releaseandholdharmlessstatementshallbindthemembersofmyfamilyandspouse,ifIamalive,andmyestate,family,heirs,administrators,personalrepresentativesorassigns,ifIamdeceased,andshallbedeemedasa“Release,Waiver,Discharge,andCovenant”nottosueWagnerCollege. Signature Date PrintName Parent/GuardianSignature(ifunderageof18) Date PrintName Relationship
Signature Date SignatureofParent/Guardian(ifStudent-Athleteisaminor) Date SignatureofPolicyHolder(ifnotstudent-athlete) Date PrintedNameofPolicyHolder Relation