Hello Temple Student-Athlete,

On behalf of the Temple University Sports Medicine Department, welcome back to Temple University.

The following material is meant to acquaint you with the policies of our Sports Medicine Department. Please take time to read and complete the necessary paperwork contained within this packet. These forms will help Temple Athletics to determine if you are medically eligible to participate in intercollegiate athletics. All completed forms will be placed into your permanent medical file that will be securely stored in our clinic for the duration of your collegiate career. Only you, upon request, as well as the Temple University Sports Medicine staff, will have access to this information.

Please note that this packet does not include all of the same information or forms that were included in the “New Student-Athlete” packet that you completed upon first coming to Temple University. If you are a Freshman, or have just recently transferred to Temple University, please contact the Sports Medicine Department or your coaching staff to have the appropriate packet sent to you.

Contact Form: In addition to providing us with your demographic information, it also provides contact information in the event of an emergency.

Athletic Injury Warning and Acknowledgement of Responsibility: By signing this form, you are indicating your understanding of the dangersinherent in, and the potential for injury involved during participation in intercollegiate athletics. Additionally, you are indicating your understandingthat you are required to notify the Temple Sports Medicine staff of all injuries/illnesses/medical conditions, both past and present.

Health Insurance Packet: These forms explain our insurance policies and provides us with your active health insurance coverage information.Copies of ALL health insurance cards (front and back), including dental, vision, and prescription medication insurance, must also be submitted.This must be completed, in its entirety, even if your personal health insurance status is unchanged from previous years.

Authorization for Use/Release of Protected Health Information: This form gives Temple University Student Health Services, Temple UniversityHospital, and Temple Sports Medicine permission to release my protected health information to Temple University’s Athletic Department, TeamPhysician, Athletic Training Staff, Insurance Coordinator, or Insurance Carrier.

Concussion Fact Sheet: By signing this form, you affirm that you have received information regarding sports-related concussions and that youunderstand your responsibility to report any suspected head injury to the Temple Sports Medicine staff.

ADD/ADHD Prescription Medication Declaration: By signing this form, you are indicating your understanding of the NCAA rules regarding theuse of stimulant medications, as well as your responsibility to disclose any prescription medication that you have recently or are currently taking.

Once you have completed these forms, please return to the Temple University Sports Medicine Department by facsimile, or directly to the athletic trainer who oversees your respective sport via email.

McGonigle Hall Athletic Training Facility - Olympic Sports: 1800 N. Broad Street, Room MG-28, Philadelphia, PA 19121 Phone # 215.204.7444 Fax # 215.204.2133

Edberg-Olson Hall Athletic Training Facility – Football: 1001 West Diamond Street, Philadelphia, PA 19122 Phone # 215.204.0873 Fax # 215.204.1881

Shortly after you arrive on campus, you will be required to complete a comprehensive physical exam that will be provided by the Temple University Sports Medicine Department. You will be contacted by your sport-specific coach or athletic trainer as to when to report for your physical examination before your preseason begins. This process will occur annually. We ask that you return this completed packet no later than 21 days prior to your scheduled pre-participation physical exam.

You will be ineligible to participate until we receive all completed forms, including proof of health insurance and sickle cell status, and have been medically cleared by one of the Temple University Team Physicians.

If you should make any mistakes or misplace any of this material, you can download additional PDF forms from our athletic website: http://www.owlsports.com/info/athletic-training.asp. Please feel free to contact us with any questions regarding these forms.

Thank you,

Temple University Department of Sports Medicine

DATE ________ (M) ________ (D) ________ (Y)

Student-Athlete & Emergency Contacts - rev. 04/18

S T U D E N T- ATHLETE & EM ER G E N CY I N F ORM AT I O N

NAME: ________________________________ ___________________ ___________ SPORT: _______________ (Last) (First) (Middle)

TU ID#: ________-_______-_________ BIRTHDATE: ___________________ E-MAIL: _______________________________ (M / D / Y)

CAMPUS/LOCAL ADDRESS:

Dorm/Building Name ____________________________________ Room # _____________ Roommate(s) _________________________

Address ______________________________________________ City__________________________ State________ Zip _____________

CELL PHONE: ______________________________________ CAMPUS/LOCAL PHONE: ___________________________________

PERMANENT/HOME ADDRESS (if different from Local Address):

Street ___________________________________________ City__________________________ State________ Zip _____________

PERMANENT/HOME PHONE: ____________________________________

ACADEMIC STANDING: (circle) FRESHMAN SOPHOMORE JUNIOR SENIOR GRAD STUDENT ATHLETIC ELIGIBILITY: (circle) FRESHMAN SOPHOMORE JUNIOR SENIOR 5th YEAR OTHER

EMERGENCY CONTACT INFO:

Mother (or Guardian) _______________________________ _____________________________ Cell Phone ______________________________ (Last) (First)

Father (or Guardian) _______________________________ _____________________________ Cell Phone ______________________________ (Last) (First)

Other Emergency Contact _______________________________ ________________________ Cell Phone ______________________________ (Last) (First)

Relationship Home/Work Phone _______________________

Address _____________________________________________ City__________________________ State________ Zip _____________

Address (If Different from Permanent)_______________________________________________________________________________________

Address (If Different from Permanent)_______________________________________________________________________________________

EMERGENCY INFORMATION:

Allergies (Food, Medicine, Environmental): ____________________________________________________________________________________

Current Medications: _____________________________________________________________________________________________________

Current Supplements or Vitamins: __________________________________________________________________________________________

Athletic Injury Warning and Student-Athlete Acknowledgement of Responsibility to Notify – rev 04/18 pg. 1

DATE ________ (M) ________ (D) ________ (Y)

NAME: ___________________________________________ SPORT: _______________ TU ID#: _______-_______-_______

ATHLETIC INJURY WARNING AND STUDENT-ATHLETE ACKNOWLEDGEMENT OF RESPONSIBILITY TO NOTIFY

Participation in sports requires an acceptance of risk of injury. Student-athletes rightfully assume that those responsible for the conduct of sport have taken reasonable precautions to minimize such risk and that their peers participating in the sport will not intentionally inflict injury upon them.

Periodic analyses of injury patterns lead to refinements in the rules and other safety decisions. However, to legislate safety via a rulebook and equipment standards, while often necessary, seldom is effective by itself; and to rely on officials to enforce compliance with the rule is as insufficient as to rely on warning labels to produce compliance with safety guidelines. “Compliance” means respect on everyone’s part for the intent and purpose of a rule or guideline.

FOOTBALL STUDENT-ATHLETES: Do not use your helmet to butt, ram or spear an opposing player. This is in violation of football rules and such use can result in severe head or neck injury, paralysis or death to you and possible injury to your opponent. No helmet can prevent all head or neck injuries a player might receive while participating in football. Never wear any other player’s helmet. Every helmet is specifically fitted to each player and may not provide adequate protection to any other player.

This annual form must be completed and returned before the student-athlete will be permitted to practice or play. The National Collegiate Athletic Association’s policies require that all student-athletes have a qualifying medical evaluation upon initial entrance into an institution’s intercollegiate athletic program, an annual “health status” review, and recommends a cardiac follow-up exam every other year. Temple University supports this NCAA policy. Further medical evaluations may be required for specific matters.

*This Section to be completed by Returning Student-athletes only.Please answer the following questions: Circle One

1 Have you been hospitalized or had a major illness since your last Health History at Temple University? Yes No

2 Are you currently ill in any way? Yes No

3 Have you had a major injury, including concussion, since your last Health History at Temple University? Yes No

4 Do you currently have any incompletely healed injury? Yes No

5 Are you currently taking any medication on a regular basis? Yes No

6 Have you had any surgery since your last Health History at Temple University? Yes No

7 Have you had any accidents or fractures since your last Health History at Temple University? Yes No

8 Have you seen a physician in the last year for any condition? Yes No

9 Do you know of, or do you believe there is, any health-related reason why you should not participate in the Temple University Intercollegiate Athletic Program at this time? Yes No

10 Would you like to discuss your current health status with the team physician? Yes No

Please explain all YES answers: ____________________________________________________________________________________________________

____________________________________________________________________________________________________

Athletic Injury Warning and Student-Athlete Acknowledgement of Responsibility to Notify – rev 04/18 pg. 2

NAME: ___________________________________________

DATE ________ (M) ________ (D) ________ (Y)

The Undersigned, herewith:

A. Understands the dangers inherent in, and the potential for injury involved during, participation in intercollegiate athletics atTemple University.

B. Acknowledges that he/she is fully aware that participation in intercollegiate athletics carries with it the risk of injury. Theserisks include:

minor sprain/strain, contusion, laceration, etc.; joint injury with or without significant internal derangement; fracture and dislocation; concussion; and catastrophic injury resulting in permanent disability of one or more joints, paralysis, and possibly death.

C. Acknowledges that information regarding concussions, including signs, symptoms, causes and complications of aconcussion, have been presented and understands this information and the importance of notifying the medical staffimmediately if he/she suspects that he/she or another student-athlete has sustained a concussion.

D. Acknowledges and accepts the responsibility to notify, immediately, the Temple University Athletics Department athletictrainers and/or team physician of all injuries, illnesses, or medical conditions that are currently experienced, or which mayoccur in the future. This includes both athletic and non-athletic conditions which might occur, as well as any medication,treatments, tests or treating facility notes which are needed in order to determine my health status.

E. Affirms that he/she fully understands that his/her failure to notify the Sports Medicine staff of injuries, illnesses, or medicalconditions in the proper fashion may put him/her at risk for further injury or exacerbation of my condition, and voluntarilyagrees to release, discharge, indemnify and hold harmless the State of Pennsylvania, The University, its officers, employeesand agents from any and all costs, liabilities, expenses, claims, demands, or causes of action on account of any loss orpersonal injury that might result from his/her non-compliance with this mandate.

F. Understands that he/she must refrain from practice while ill or injured whether or not he/she is receiving medical treatmentuntil he/she is discharged from treatment, or has been given permission by the clinical practitioner to restart participationdespite continuing treatment.

G. Understands that having passed the physical examination does not necessarily mean that he/she is physically qualified toengage in athletics, but only that the evaluator did not find a medical reason to disqualify him/her at the time of theexamination.

H. Certifies that the answers to the questions above are correct and true.

Signature: _____________________________________________________ Date: ____________________ Name (printed): ____________________________________________________

*If under 18 years of age:

Parent/guardian signature: ____________________________________________ Date: ____________________

Temple University Health Insurance Information – rev 04/18 pg. 1

TEMPLE UNIVERSITY HEALTH INSURANCE INFORMATION

Welcome Temple Student-Athletes,

We hope the following helps to explain our athletic insurance policy and referral procedures; and that it answers any questions you may have concerning the health insurance requirements for participation in intercollegiate athletics at Temple University. Please share this information with your parent, legal guardian, and/or whomever is the policy holder for your current health insurance plan.

Our goal is to provide the best possible health care for our student-athletes. To achieve this goal, communication and cooperation between the attending physician and our Sports Medicine Department are essential from the time of injury through complete resolution. Additionally, your cooperation in adhering to the policies and procedure, outlined here, will enhance care and is necessary to make claims against Temple Athletics excess insurance policy.

Am I required to have Personal Primary Health Insurance coverage? ALL TEMPLE UNIVERSITY STUDENT-ATHLETES ARE REQUIRED TO HAVE INDIVIDUAL HEALTH INSURANCE COVERAGE BEFORE PARTICIPATING IN ANY INTERCOLLEGIATE ATHLETIC ACTIVITY. THIS MUST BE MAINTAINED THROUGHOUT THE PARTICIPANT’S ATHLETIC CAREER AT TEMPLE UNIVERSITY. The student-athlete’s (including international students) insurance policy must cover athletics-related injuries and/or illnesses up to $90,000 per incident, and shall be considered the primary insurance coverage for all athletic-related injuries. The student-athlete must have coverage local to Temple University, in the Greater Philadelphia area. The student-athlete must complete a Health Insurance Information/Authorization Form (included in this packet) and supply a photocopy (front & back) of the health insurance card on an annual basis. The Temple University Sports Medicine Office must receive any changes to a health insurance policy as soon as they occur. If proper notification is not received, the Temple University Department of Athletics may not be responsible for any delays in payment, collections notices, credit reports, etc. that occur.

What options do I have if I do not currently have Personal Primary Health Insurance coverage that meets the above criteria? Temple University offers full-time undergraduate and graduate students, including international students, the opportunity to purchase student health insurance at reduced group rate through Independence Blue Cross Personal Choice PPO Plan. If you cannot afford the student insurance offered by Temple University, and choose to enroll in other programs providing low cost insurance coverage, please be sure to verify the above minimum standards.

What type of athletic insurance does the Temple University Athletic Department carry? As a service to our student-athletes, the Temple University Athletic Department provides a supplemental athletic accidental insurance policy. This policy, however, is secondary to, or in excess of, personal primary medical insurance coverage and only covers injuries/illnesses/accidents resulting from the direct participation in the intercollegiate athletics program during the dates of the primary competitive season and designated off-seasons as approved by the Director of Athletics according to NCAA regulations. All care must be coordinated through the Sports Medicine Department staff prior to any ER, hospital or doctor’s visit, or diagnostic procedure.

The excess insurance policy requires that the injured student-athlete first make a claim under their primary medical or hospitalization insurance. Medical expenses not covered by the primary insurance will be paid under the school's policy (subject to its limitations and conditions). Although we attempt to purchase the most comprehensive policy within our resources, this is not an all-inclusive policy.

How do I qualify for this coverage? As a Temple University student-athlete, you are automatically covered under this policy, as stated above, assuming that you have completed and returned to the Temple University Sports Medicine Department all required primary insurance information, under which you are covered. These forms, along with a photocopy of the applicable medical insurance I.D. card(s) - front & back - must be on file in the athletic training room prior to participation in athletic-related physical activity.

How does the insurance work? The excess insurance policy requires that the injured student-athlete first make a claim under the primary insurance. We send your primary insurance information along with you, or directly to the provider, when you are referred for care. The provider should file a claim with your insurance company for the services rendered. Your health insurance carrier will evaluate the claim and either pay you or the

Temple University Health Insurance Information – rev 04/18 pg. 2

provider directly, or deny the claim. If the provider does not file with the primary insurance, the provider may send you a bill for you to file with your insurance company.

If after 60 days from the date of injury, you have not received anything from your insurance company: 1. Call your insurance company to check the status of the claim, and/or2. Submit the bill from the provider to your insurance company.

We will also send the providers our excess insurance information and notify our insurance company that a claim may be forthcoming. Temple University Department of Intercollegiate Athletics’ Health Insurance Coordinator, Sandra Rodville, will file a claim against our secondary insurance company after your primary insurance has been exhausted.

*All claims must be resolved with the secondary insurance company within 104 weeks of the date of injury. Temple University and theAthletic Department’s excess insurance carrier, are not responsible for any charges associated with the injury beyond this 104 weekbenefit period.

When is a student-athlete referred to a physician? Whenever the team physician or the athletic trainers are of the opinion that a consultation would facilitate/improve the care of an injury, arrangements for such a visit will be made. Coaches do not have the authority to refer a student-athlete to any physician except for emergency care when the Sports Medicine staff is not available.

What if I belong to an HMO? If you belong to a Health Maintenance Organization (HMO), you may be limited to specific physicians and/or facilities. You are requested to send us specific instructions, requirements, and/or limitations which may be included with the policy. This information is necessary for the claims process to be filed correctly. Failure to follow the proper HMO procedures will void your eligibility under the athletic department's excess health insurance policy. We have included a questionnaire with this Health Insurance packet to help you gather this information when contacting your health insurance company. In may be in your best interest to select a PCP local to Temple University.

Dr. Cory Keller, D.O., Dr. Eric Kropf, M.D, Dr. Michelle Noreski, D.O., Dr. J. Milo Sewards M.D., and Dr. Ryan Schreiter, D.O, of Temple University Orthopedics and Sports Medicine, are the official team physicians for all intercollegiate sports sponsored through Temple University. The Orthopedic and Sports Medicine office is considered a specialist service by all insurance companies, so these team physicians are not typically eligible to be selected as primary care physician by most health insurance companies.

To provide the best possible health care to our student-athletes, the Athletic Training Division of Temple University is requesting that all athletes who have an insurance that requires a referral or has capitated radiological sites, nominate Temple General Internal Medicine (please see address below) as their primary care provider. To make this change, you will need to contact your insurance company prior to arriving at Temple University.

Lawrence (Larry) Kaplan, MD Temple General Internal Medicine Associates 1316 W. Ontario Street Philadelphia, PA 19140-5220 Phone: 215-707-7901

If Temple General Internal Medicine is not listed under your insurance plan, please contact the Sports Medicine staff at (215)204-3687 and we will attempt to help you find a physician or group in the area. Your efforts now will help expedite your care in the event of an injury.

Please understand that Temple Athletics is not directly affiliated with Temple Internal Medicine. We have simply found, over the years, that this group has been very accommodating when dealing with our student-athletes. They are also located near to Main Campus, adjacent to Temple University Hospital. Temple University has a bus system that provides free transportation to Temple students going to Temple University Hospital.

Temple University Health Insurance Information – rev 04/18 pg. 3

Which physicians can a student-athlete see under the Temple Athletics excess insurance plan? For a student-athlete to be covered under the athletic department's secondary insurance, they must be seen by either a Temple University team physician or designated specialist, and receive a written referral for medical treatment from the Temple University Sports Medicine Department. The Sports Medicine Department has developed a relationship with a wide range of specialists from the local area that can be called upon to provide medical care for our student-athletes. Using these physicians helps to ensure that appropriate medical care is received, and that accurate and continuous communication between the physicians and the Temple University Sports Medicine Staff is achieved.

*Prior written authorization must be obtained if a student-athlete wishes to seek medical attention outside of this network.

If a student-athlete seeks a second opinion or care from an outside physician, he/she will be medically ineligible to participate in athletics or utilize the services of the Temple University Sports Medicine Program until medical records are received and reviewed by the Temple University Sports Medicine Staff. The student-athlete has the responsibility to see that all requested information is forwarded from the treating physician’s office. You also assume the financial responsibility for any travel costs and the services of the provider. Our excess insurance policy cannot be applied to those services.

Towards which bills can the excess insurance policy coverage be applied? The athletic department's excess insurance policy can be applied only to those bills that result from an injury incurred while participating in a Temple University sanctioned practice or game, and:

• When prior approval for a referral was granted through the Temple University Sports Medicine Staff.• When the care has been coordinated through the Temple University Sports Medicine Staff.• For services rendered by the approved medical care provider.• For care rendered within 104 weeks of the date of injury.• After your insurance company has responded to and resolved all claims.

What types of things are not covered under this insurance plan?

• Any injury sustained in an activity that is not associated with a supervised intercollegiate practice or competition supervised bya coach.

• A chronic or recurrent injury that was sustained prior to participation in athletics at Temple University.• Any degenerative condition, as diagnosed by the team physician.• Any illness (cold, flu, infection, etc.).• Unauthorized consultations or treatments.• Conditions as a result of non-compliance with the school's policies, team rules, or the advice of the team physician, attending

physician(s), athletic trainer(s) or coach.• Any injury that is not reported to the athletic trainers within 7 days of occurrence or onset of symptoms.• Any services rendered beyond the 104 week benefit period.

What are the student-athlete's responsibilities? It must be clearly understood that you are responsible for the resolution of all claims. The Athletic Department of Temple University assumes no financial liability for expenses generated for medical care of a student-athlete. We will attempt to relieve any financial burden that may occur from the care of athletic injuries. However, this is not an all-inclusive policy and benefits will be applied subject to the terms and limitations of this policy.

You are required to complete the attached forms, regarding your health insurance coverage. In signing the attached forms, you acknowledge that the information provided is, to the best of your knowledge, true and accurate. You also acknowledge that you have received a copy of this information and that you understand the policies and procedures outlined within.

Keep this information for reference throughout the year. Please return the attached pages to the Temple University Sports Medicine Department upon completion.

Temple University Health Insurance Information – rev 04/18 pg. 4

Where can I get more information? We are willing to advise you through this process. Should you have any questions or problems during the claims process, please feel free to contact Sandra Rodville at (215) 204-9302.

All of our forms can also be downloaded via the Temple Athletics website. In addition, you will find contact information for our staff members. Our web address is: http://www.owlsports.com

Thank you for your cooperation,

Temple University Department of Sports Medicine

*This summary is informational only and is subject to the terms and conditions of the applicable insurance policy. Also, this insurancepolicy can be cancelled at any time with no prior notice.

Personal Health Insurance Information – rev. 04/18 pg. 1

DATE ________ (M) ________ (D) ________ (Y)

NAME: ___________________________________________ SPORT: _______________ TU ID#: _______-_______-_______

PERSONAL HEALTH INSURANCE INFORMATION

Primary Health Insurance Information

Primary Health Ins. Company: Type: HMO PPO POS OTHER

Policy Number: Group Number:

Ins. Co. Phone Number: Are referrals required: YES NO

Ins. Co. Address:

Policy Holder Name: Date of Birth:

Relationship to Student-Athlete: Phone Number:

Policy Holder Address:

This policy includes: Dental: YES NO Mental Health Services: YES NO Vision: YES NO Psychiatric Medicine: YES NO Prescription (Rx): YES NO - if yes Rx. Bin: ______ Rx. PCN: ______ Rx. Group: _______

Please list the name of all other medical coverage that you subscribe to (in addition to the above primary policy)

Medical (Secondary): ______________________________ Dental: ________________________________________ Prescription: _____________________________________ Vision: _________________________________________ Other: _________________________________________

To maximize your health benefits and simplify the process of receiving medical services while at school, the Temple University Department of Sports Medicine asks that you contact your insurance company and/or the benefits provider to determine eligibility in the Philadelphia area. The following worksheet is designed for you to use when you call your insurance company.

Does my insurance cover outpatient care in Philadelphia? YES NO If yes, where am I capitated to? ______________________________ *If not, it may be necessary to change your insurance coverage to ensure prompt and effective care while on campus.

Do I need a referral from my PCP for specialists or outpatient services? YES NO If yes, please list: PCP Name: ______________________________ Phone Number: ____________________

Do I need precertification for medical testing (X-ray, MRI, CT, etc.)? YES NO If yes, for what services: _____________________________________________________________________

Do I have an HMO plan? YES NO If yes, do I have out-of-network benefits? YES NO If I do not have out-of network benefits, can I select a primary care physician in Philadelphia? YES NO Is Dr. Lawrence Kaplan, of Temple General Internal Medicine, a participating provider? YES NO If he is not, are there any other primary care providers in Philadelphia that are participating providers? *Please consider making this change, effective immediately.

Is proof of full-time student status necessary for coverage? YES NO If yes, has this been submitted for the upcoming academic year? YES NO

Personal Health Insurance Information – rev. 04/18 pg. 2

NAME: ___________________________________________

DATE ________ (M) ________ (D) ________ (Y)

Please list the following information for your Primary Care Physician

Primary Care Physician Information for HMO Policy Holders

PCP Name: PCP Practice Name:

Phone Number: Fax Number:

Address:

Reason for Last Exam: Date of Last Exam:

Your personal health insurance information is used to establish your eligibility to participate in intercollegiate athletics at Temple. It is the responsibility of the student-athlete to provide Temple University Department of Sports Medicine with accurate, up-to-date information regarding current health insurance coverage, as well as any changes to his/her coverage throughout the academic year. Failure to do so may affect your ability to participate or result in delays in payment that may negatively affect the student-athlete’s credit score.

( check boxes)

□ I acknowledge that the above information is, to the best of my knowledge, true.

□ I acknowledge that I have read and understand the health insurance policies and procedures that were included with these forms.

□ I hereby authorize the athletic Department to file a claim on my behalf under the above group medical policy, and I agree and consent that anymoneys payable under this policy be paid to the medical provider or to Temple University Athletic Department as provided below.

□ I authorize payment of medical benefits to all providers for all services and materials they provide during the care of an injury/illness.

□ I agree to supply all information requested by my primary insurance, Temple University and their excess insurance company in a timely mannerin order to expedite the claims process.

□ I hereby authorize Temple University and their excess insurance company to secure and inspect copies of case history records, lab reports,diagnoses, x-rays, and any other data pertaining to the injury/illness I am receiving care for or previous confinements or disabilities relevant to thecare of the injury/illness.

□ I authorize the Sports Medicine staff of Temple University to hospitalize and secure treatment for me for any athletic injury/illness. If the athlete isunder 18 years of age, the undersigned parent grants permission to the Sports Medicine staff of Temple University to hospitalize and securetreatment for their son/daughter for any athletic injury/illness.

□ A photostatic copy of this authorization shall be deemed as effective and valid as the original.

□ I will notify the Sports Medicine Staff of Temple University immediately upon any change in the above health insurance.

Student-Athlete Name (printed): ____________________________________________________ Date: ____________________

Student-Athlete Signature: ____________________________________________________

*If under 18 years of age:Parent/Guardian signature: ____________________________________________________

If the Student-Athlete is not the primary policy holder, as indicated on the previous page, the policy holder must sign below:

Policy Holder Signature: ____________________________________________________ Date: ____________________

liffiD......�w Concussion and Injury Reporting Acknowledgement

Student-Athlete Concussion Statement

_ I understand that it is my responsibility to report all injuries and illnesses to my athletic trainer and/or team physician.

I have read and understand the NCAA Concussion Fact Sheet.

After reading the NCAA Concussion Fact Sheet, I am aware of the following information (please initial beside each statement):

--- A concussion is a brain injury, which I am responsible for reporting to my team physician orathletic trainer.

___ A concussion can affect my ability to perform everyday activities, and affect reaction time, balance, sleep, and classroom performance.

___ You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury.

___ If I suspect a teammate has a concussion, I am responsible for reporting the injury to my team physician or athletic trainer.

___ I will not return to play in a game or practice if I have received a blow to the head or body that results in concussion-related symptoms.

___ Following concussion the brain needs time to heal. You are much more likely to have a repeat concussion if you return to play before your symptoms resolve.

___ In rare cases, repeat concussions can cause permanent brain damage, and even death.

Signature of Student-Athlete Date

Printed name of Student-Athlete

Date of Most Recent Impact Test ATC Signature

Concussion and Injury Reporting Acknowledgement Student-Athlete Concussion Statement – rev. 04/18

ADD/ADHD Prescription Declaration Form - rev. 04/18

DATE ________ (M) ________ (D) ________ (Y)

NAME: ___________________________________________ SPORT: _______________ TU ID#: _______-_______-_______

ADD/ADHD PRESCRIPTION DECLARATION FORM

The NCAA bans classes of drugs that can be harmful to student-athletes and that can create unfair advantages during competition. Some medications that student-athletes are prescribed for legitimate medical reasons contain NCAA banned substances. The NCAA has a Medical Exceptions Procedure to review and approve the use of medications that contain NCAA banned substances. As of August 1, 2009, the NCAA now requires documentation of a comprehensive clinical evaluation to support treatment of ADD and ADHD with NCAA banned substances and current prescription. These medications include Ritalin, Strattera, Adderall, Concerta, Focalin, etc.

At a minimum, student-athletes currently undergoing treatment for these and similar conditions using NCAA banned substances must provide the following documentation from the prescribing physician:

1. Record of comprehensive clinical evaluation (recording observations and results from standardized rating scales and/orneuropsychological testing), a physical exam and any lab work (attaching all documentation);*A simple statement from a prescribing physician that he/she is treating the student-athlete for a condition with the prescribedstimulant IS NOT adequate documentation*

2. Statement of physician diagnosis, including when diagnosis was confirmed;3. History of treatment for ADHD, ADD, or like conditions (previous and ongoing)4. Statement that a non-banned alternative has been considered and why banned stimulant was prescribed;5. Annual follow-up with prescribing physician and updated letter or copy of medical record is required in each year of eligibility; and6. Copy of most recent prescription of banned substance.

• If no assessment or diagnostic testing has been performed to diagnose ADHD, the student-athlete must be referred for testingand assessment.

• If diagnostic assessment was performed more than 5 years ago, documentation of ongoing treatment must be obtained.

Impact on NCAA Drug-Testing Program Temple student-athletes are selected at random for periodic drug testing throughout the year. If the proper documentation is not on file and the student-athlete fails a drug test due to the ADD/ADHD medication, the athletic training staff will NOT be able to appeal for a medical exemption. If a student-athlete tests positive for a banned substance on a NCAA drug screening, he/she is rendered ineligible for competition for one calendar-year (365 days) and loses a year of eligibility.

I, ______________________________________ affirm that I have read the above statement from the Temple University Sports Medicine Department about the NCAA Banned Substances List and Medical Exemptions Policy as it specifically pertains to the use of banned stimulant medications listed above that are used to treat ADD/ADHD and like conditions. I attest that:

Initial___________ I AM NOT presently taking and/or have taken within the last 12 months any banned stimulant medications (e.g. Ritalin, Strattera, Adderall, Concerta, Focalin, etc) that are used to treat ADD, ADHD, or like conditions

(or)

Initial___________

I AM presently taking and/or have taken within the last 12 months banned stimulant medications (e.g. Ritalin, Strattera, Adderall, Concerta, Focalin, etc) that are used to treat ADD, ADHD, or like conditions.

Medication:___________________________________________________________________________________________

I, the undersigned, do hereby affirm that I understand that I am to immediately notify a member of the Temple University Sports Medicine Department should I ever be prescribed the outlined stimulant medications and that I must obtain and submit appropriate documentation from the prescribing physician.

Signature: ________________________________________________________ Date: ____________________ Name (printed): ____________________________________________________

*If under 18 years of age:

Parent/guardian signature: ____________________________________________ Date: ____________________

Authorization for Use/Release of Protected Health Information – rev. 04/18

DATE ________ (M) ________ (D) ________ (Y)

NAME: ___________________________________________ SPORT: _______________ TU ID#: _______-_______-_______

AUTHORIZATION FOR USE/RELEASE OF PROTECTED HEALTH INFORMATION

1. Authorization. I, _____________________________________, hereby authorize Temple University Student Health Service, Temple UniversityHospital, Temple Sports Medicine, and/or any other medical institution which might render medical treatment to me to release my protected healthinformation to Temple University’s Athletic Department, Team Physician, Athletic Training Staff, Insurance Coordinator, or Insurance Carrier. Ihereby authorize the release of any and all records in the possession of the medical institutions listed above. I understand that the information in myhealth records might include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or humanimmunodeficiency virus (HIV). It may also include information about behavior or mental health services, genetic testing, and treatment for alcoholand drug abuse.

2. Purpose. The purpose of this authorization is to inform the recipients of my medical condition, treatment plan, and capabilities related to myparticipation in athletic competition for Temple University and to help direct my academic advisement needs.

3. Revocation Rights. I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification toTemple University Department of Sports Medicine. I understand that the revocation will not apply to information that has already been released inresponse to this authorization. I also understand that my revocation is not effective to the extent that the persons I have authorized to use and/ordisclose my protected health information have acted in reliance upon this authorization.

4. Re-disclosure. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient andno longer protected by federal laws and regulations regarding the privacy of my protected health information. For example, information may beshared with university faculty members or administrators.

5. Expiration Date. Unless otherwise revoked, this Authorization will expire on the earlier of one year following the date of signature, below, or onthe date of my separation from the Temple University Athletic Program.

6. Copies. I understand that a photo copy of this authorization shall be considered as effective and valid as the original. I understand that I mayreceive a copy of this Authorization. I understand that I may inspect or copy the information to be used or disclosed.

7. Treatment. I understand that authorizing the disclosure of this health information is voluntary and that I can refuse to sign this authorization. Themedical institutions listed above may not condition treatment or payment on whether I sign this Authorization.

Signature: ____________________________________________________ Date: ____________________ Name (printed): ____________________________________________________

*If under 18 years of age:

Parent/guardian signature: _______________________________________________ Date: ____________________