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Authorization to Release Information-Part III
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- If under 18 yrs. of age, parent/guardian
- If you are signing the Waiver only fill out Page 14 Sickle Cell Testing Waiver Form About Sickle Cell Trait
- Sickle Cell Trait Testing- The NCAA, St. Joseph’s Candler Sports Medicine and Armstrong Atlantic State University Athletics Department
- SICKLE CELL TRAIT TESTING WAIVER
- (if under 18 years of age)
- Sickle Cell Trait Positive
- Concussion and Injury Reporting Agreement Form
- The Armstrong Atlantic State Athletic Department Consent to Drug Test and Authorization for Release of Information
- The Undersign (Athlete, Parent/Guardian) herewith
- *Upon the completion of the History Form, it is to be reviewed and signed by a Staff Certified Athletic Trainer.
Authorization to Release Information-Part IIII hereby authorize and request AASU and St. Joseph’s/Candler athletic trainers and/or their consulting physician(s) to furnish any and all requested information to St. Joseph’s/Candler and/or Optim Health, P.C. physicians, University coaches and administration, professional teams, their agents, scouts, or athletic trainers which directly pertains to my athletic participation in athletics at AASU. Said authorization shall include, but is not limited to: information concerning my physical condition, illnesses, injuries, treatments, hospitalizations, examinations, X-rays, or other forms of diagnostic testing. I hereby fully discharge all parties to whom this authorization extends from any and all penalties of breach student-athlete confidentiality. This authorization period is effective until I am no longer an active athlete at AASU. Additionally, I understand that an additional release form may be required to release information to outside entities in the event that an injury occurs outside of Savannah, Georgia. ______________________________________________ ____________________________________________________ Student-Athlete Printed Name Parent/Guardian Signature _______________________________________________________ If under 18 yrs. of age, parent/guardian Student-Athlete Signature MUST SIGN ______________________________________________ Today’s Date Student Athlete Sickle Cell Trait To-Do The NCAA is mandating that all student-athletes must be tested for sickle cell trait, show proof of a prior test or sign a waiver releasing the Institution of liability if they decline to be tested. In accordance with this legislation, the Armstrong Atlantic State University Sports Medicine Department is mandating that all student-athletes must be tested for sickle cell trait, show proof of a prior test or sign a waiver releasing the State of Georgia, the University, its officers, employees and agents from any and all costs, liability, expense 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, St. Joseph’s Candler Sports Medicine and Armstrong Atlantic State University Athletics Department Student-Athletes Need to: Contact their parents/guardian and your pediatrician (at birth) and get documentation showing what your sickle cell trait status is. Infants born after 1984 were tested for the sickle cell trait and therefore the documentation should be available from your family pediatrician. OR Schedule an appointment with Health Services at the Student Affairs Annex for a Sickle Cell trait blood test. All appointments must be made before 2:30pm. There is a charge for this test. OR Sign a waiver releasing the State of Georgia, the University, its officers, employees and agents from any and all costs, liability, expense 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, St. Joseph’s Candler Sports Medicine and Armstrong Atlantic State University Athletics Department. The signing of the waiver is not recommended. It is preferred that all student-athletes know their status to help ensure their health and wellbeing during participation in athletics. We are advising all student-athletes to consult with their parent or guardian before signing the waiver. If you are signing the Waiver only fill out Page 14 Sickle Cell Testing Waiver Form 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 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 “log jam” blood vessels, leading to collapse from the rapid breakdown of muscles starved of blood. Sickle Cell Trait Testing- The NCAA, St. Joseph’s Candler Sports Medicine and Armstrong Atlantic State University Athletics Department mandates that all NCAA student-athletes have knowledge of their sickle cell trait status, show proof of a prior test or sign a waiver before the student-athlete participates in any intercollegiate athletics event, including strength and conditioning sessions, practices, competitions, etc. The Chatham County Health Department offers sickle cell trait screening in the form of a blood test to all students for a fee. Results will be reported to Armstrong Atlantic State Athletics Department and/or a member of the Armstrong Atlantic State Sports Medicine Department. Athletes should read through Armstrong Atlantic State University Sickle Cell Position Statement. SICKLE CELL TRAIT TESTING WAIVER I, _______________________________, understand and acknowledge that the NCAA, SJCHS and AASU Athletics mandates that all students 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 SJCHS and AASU Sports Medicine personnel. I do not wish to undergo sickle cell trait testing and I voluntarily agree to release, discharge, indemnify and hold harmless the State of Georgia, the University, St. Joseph’s Candler Hospital 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, SJCHS and Armstrong Atlantic State University Athletics Department 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 Date _________________________________________________ ___________________ Parent/Guardian Signature (if under 18 years of age) UID # __________________________________________________ ___________________ Parent/Guardian Print Name Date __________________________________________________ ___________________ Witness Date Sickle Cell Disclosure Form I, ______________________________________ affirm that I have been informed by my family physician as to my Sickle Cell Trait Status, and/or have undergone the sickle cell trait screening, in the form of a blood test. 1. Sickle Cell Trait Positive Initial ___________ 2. Sickle Cell Trait Negative Initial ___________ About Sickle Cell Trait- Sickle cell trait is an inherited condition of the oxygen-carrying protein, hemoglobin, in the red blood cells. 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. Likely sickling settings include timed runs, all out exertion of any type for 2 – 3 continuous minutes without a rest period, intense drills and other spurts of exercise after prolonged conditioning exercises, and other extreme conditioning sessions. Common signs and symptoms of a sickle cell emergency include, but are not limited to: increased pain and weakness in the working muscles (especially the legs, buttocks, and/or low back); cramping type pain of muscles; soft, flaccid muscle tone; and/or immediate symptoms with no early warning signs. I, the undersigned, do hereby affirm that I have been informed of my sickle cell trait status by my family physician and/or one of the clinicians at Armstrong Atlantic State University Sports Medicine Department. If my sickle cell trait status is positive I understand that I am required to undergo educational sessions around the topic of sickle cell and understand that specific precautions that need to be undertaken due to the serious nature of the condition. The educational sessions will be administered by the Armstrong Atlantic State University Sports Medicine Department. I also affirm that I have read through Armstrong Atlantic State University Athletics Sickle Cell Position Statement. ______________________________________________________ ___________________ Student-Athlete Signature (If under 18, include parent/guardian signature) Date ______________________________________________________ ___________________ Examining Physician Signature Date ___________________________________________________________ _____________________ Examining Physician Print Name Date ____________________________________________________________ _____________________ Athletic Trainer Signature Date Concussion and Injury Reporting Agreement Form NCAA regulations require all varsity student-athletes to be aware of what a concussion is, as well as signs and symptoms of concussion. Please read the below information and sign and date the bottom of the form to be in compliance with NCAA regulations. What is a concussion? A concussion is a brain injury that may be caused by a blow to the head, face, neck, or elsewhere on the body with an “impulsive” force transmitted to the head. Concussions can also result from hitting a hard surface such as the ground, ice or floor, from players colliding with each other or being hit by a piece of equipment such as a bat, lacrosse stick, or field hockey ball.
to light, sensitivity to noise, feeling sluggish, hazy, foggy, or groggy, concentration or memory problems, confusion.
responsibility for reporting all injuries and illness to the Armstrong Atlantic State University Sports Medicine Staff, including signs and symptoms of concussion. Signature of Athlete________________________________________ Date_______________ Sport(s)______________________________________________________ Request parent/guardian signature if student-athlete is under 18 years old Parent/Guardian Signature__________________________________ Date________________ The Armstrong Atlantic State Athletic Department Consent to Drug Test and Authorization for Release of Information I hereby acknowledge receipt of a copy of the Armstrong Atlantic State Department reasonable suspicion and voluntary drug testing program for student-athletes. I further acknowledge that I have read this policy and fully understand its provisions. It is my understanding that signing this consent form and returning it is a prerequisite to becoming a member of the intercollegiate team at Armstrong Atlantic State. I further understand that I may refuse to sign this consent form, but as a consequence, I must forego participation in intercollegiate sports at the University. I am aware that I am expected to abide by team rules, that such rules are subject to change, and that I may be dismissed from the team and/or deprived of my grant-in-aid or scholarship for failure to abide by such rules. I acknowledge my understanding that the use or abuse of drugs not prescribed by a physician for a specific medical condition is a violation of team rules. I hereby consent to have samples of my urine collected and tested for the presence of certain drugs or substances in accordance with the provision of the Armstrong Atlantic State Drug Testing Program. I further authorize the Team Physician at Armstrong Atlantic State to make a confidential release to the head coach of any intercollegiate sports in which I am a team member, the Athletic Director at Armstrong Atlantic State and, if a minor, my parent(s) or legal guardian(s), all information and records, including test results you may have relating to the screening or testing of my urine sample(s) in accordance with the provision of the Armstrong Atlantic State Drug Testing Program which is applicable to all intercollegiate athletes at Armstrong Atlantic State. To the extent set forth in this document, I waive any privilege I may have in connection with such information. I further agree that, in the event the results of my drug screening test are positive, I will follow the procedures stated in the section of the policy entitled “Positive Test Results” Armstrong Atlantic State, its Board of Trustees, its officers, employees and agents are hereby released from legal responsibility or liability for the release of such information and records as authorized by this form. Parent’s Signature ____________________ (if student-athlete is under 18) Student-Athletes Signature _____________________________ Print Full Name_________ __________________
(907)Number –Student ID number ____________________________________ Intercollegiate Sport The Undersign (Athlete, Parent/Guardian) herewith, Understands that any medical expense incurred due to the above pre-existing conditions and not directly attributed to athletic participation at Armstrong Atlantic State University is his/her personal responsibility. Understands that the athletic medical insurance is secondary coverage and does not cover him/her until he/she has been cleared by an athletic pre-participation physical examination. Understands that it is his/her responsibility to report all injuries/illnesses to his/her staff certified athletic trainer as soon as possible. Understands that he/she must refrain from practice(s), and/or game(s), per direction of staff certified athletic trainers and/or physician orders, until he/she is discharged or given permission by staff certified athletic trainer to restart participation despite continuation of treatment. Understands that having passed the pre-participation physical examination does not necessarily mean he/she is physically qualified to engage in athletics, but only that the evaluator(s) did not find a medical reason to disqualify him/her at said time of evaluation. Understands that the athlete will not be allowed to participate in any intercollegiate athletics until all forms are complete. Certifies that the above answers are correct and true. ______________________________________________________ _____________________________ Athlete’s Printed Name Date
______________________________________________________ Athlete’s Signature _____________________________________________________ _____________________________ Parent/Guardian Printed Name Date (if Athlete under age of 18) _____________________________________________________ Parent/Guardian Signature (if Athlete under age of 18)
____________________________________________________ _____________________________ Staff Certified Athletic Trainer Signature Date Directory: insideAthletics -> copy of sportsmedicine copy of sportsmedicine -> Gender: m f age: D. O. B Download 249.73 Kb. Share with your friends:
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