Wartburg College Sports Medicine

Pre-Participation Exam Packet

Dear Student-Athlete,

Welcome to Wartburg College athletics. This packet contains all of the medical paperwork that

you are required to complete and submit prior to being medically cleared for athletic participation.

Upon completing these required forms please return them by mail, fax or email to:

Ryan Callahan

Head Athletic Trainer

100 Wartburg Blvd

Waverly, IA 50677

319-352-8534

Fax: 319-352-8528

Email: ryan.callahan@wartburg.edu

These forms should be completed and returned by August 1st. Please note that physical exams

must completed specifically for participation in college athletics and completed after June 1st so that

they cover the full year of athletics (August-May). Physical exams completed for high school

participation or in the previous calendar year will not be accepted per NCAA policy. Pre-participation form checklist:

o Physical Exam Form- This form must be signed off by a Medical Doctor (MD), Doctor of Osteopathy (DO), Nurse

Practitioner (ARNP), or Physician Assistant (PA). Other providers will not be accepted per NCAA regulations.

o Insurance and Medical Expense Coverage Policy (Read Only)

o Athletic Insurance Form

o Front and back copy of health insurance card (No form in packet-attach card copies)

o Sickle Cell Trait Disclosure/Waiver Form

o Assumption of Risk Form

o ADHD Notification Form

o Concussion Statement

o Institutional Drug Testing Consent Form

o Release of Health Information

o Athlete Connection Form-This form will instruct you in completing your student-athlete profile in the athletic

training room’s electronic medical database. This profile is required for you to receive sports medicine services

and only takes a few minutes to complete.

***All forms in this packet must be completed and submitted before you can participate***

WARTBURG COLLEGE STUDENT ATHLETE PHYSICAL EXAMINATION FORM

Sport(s):___________________________________________________

Year in College: 1st 2nd 3rd 4th Transfer International

Name: ____________________________________________________

(First) (Middle) (Last)

Birth Date: ____________________ Sex: M F Other:___________

(Month) (Day) (Year) Gender: ________________________

Blood Pressure: _________/__________ Pulse:_______________

Height: _____________ (inches) Weight: _________(pounds)

Vision: R: 20/___ L20/____ Corrected: Y N Pupils: Equal__ Unequal___

Allergies: ____________________________________________________

Medical Normal Abnormal Findings

Appearance

Eyes, Ears, Nose, Throat

Lymph Nodes

Heart

Pulses

Lungs

Abdomen

Genitourinary (males only)

Skin

Neck

Musculoskeletal

Neck

Back

Shoulders/Arms

Elbows/Forearms

Wrists/Hands/Fingers

Knees

Legs/Ankles

Foot/Toes

This form is required to be signed off by a Medical Doctor (MD), Doctor of Osteopathy (DO), Nurse Practitioner

(ARNP), or Physician Assistant (PA). Other providers will not be accepted per NCAA regulations.

REQUIRED IMMUNIZATIONS (Below are requirements of Wartburg College)

Measles/Mumps/Rubella (2 MMRs Required)

Dose #1: (mm/dd/yr) _____________ Dose #2: (mm/dd/yr) _____________ Tdap (mm/dd/yr) ______________

HIGHLY RECOMMENDED

IMMUNIZATIONS

Meningococcal: (Meningitis)

Dose #1: (mm/dd/yr) _____________

Dose #2: (mm/dd/yr) _____________

Clearance for Athletics

_____ Cleared for participation in (list sports)____________________________________________________________

_____ Cleared after completing evaluation/rehabilitation for:_______________________________________________

_____ Not cleared for _______________________________ Reason:________________________________________

Health Care Provider (signature required)

Date: __________________________ Signature:_______________________________________________

Clinic Name:____________________________ Provider Name: (Print):_____________________________________

Address: ________________________________________________________________________________________

Phone:________________________________________ Fax:_________________________________________

Wartburg College Athletic Insurance and Medical Expense Coverage Policy

Wartburg College provides first-class medical care for those students participating in intercollegiate athletics and

recognizes their health, safety and well-being as a critical portion of their college experience. For that reason, Wartburg

provides student-athletes with a well-rounded sports medicine team to meet any healthcare needs that arise from their

participation in athletics. Please review this document to ensure your understanding of how Wartburg College uses its

providers and the party responsible for payment.

Primary Health Insurance

Wartburg College and the NCAA require that ALL student-athletes possess a primary health insurance policy that

covers athletic-related injuries in order to practice or compete. This policy must be submitted to Wartburg College

Sports Medicine before a student-athlete will be cleared for participation. If a student-athlete sustains in injury in

which claims or expenses for an injury reach $90,000 the NCAA’s catastrophic insurance plan covers the medical costs

for an injured student-athlete to ensure they have access to the care they need.

Health insurance for “emergencies only” in the Waverly area will greatly limit Wartburg’s ability to refer an injured

student-athlete to a provider in our network. The sports medicine department will assist you in obtaining a plan that

will provide benefits in the Waverly area at your expense.

Medical Expense Coverage Summary

Wartburg College Athletic Training Services: All services provided by Wartburg College Certified Athletic Trainers

(ATC) are at no charge to student-athletes. These services include injury evaluation, treatment and rehabilitation.

Taylor Physical Therapy Services: Services provided by Taylor Physical Therapy employees (Physical

Therapists/Physical Therapy Assistants) will not be billed to student-athletes. Taylor Physical Therapy will bill services

to your health insurance policy but any amount of that service not covered by insurance (co-pay, Co-insurance,

Deductible) will be paid by Wartburg College. Note-You will receive an Explanation of Benefits from your health

insurance company with these charges. However, you will not receive a bill from Taylor Physical Therapy.

All other Medical Providers/Services: Any other medical expense related to a student-athlete’s participation in

intercollegiate athletics is the student-athlete’s responsibility. Providers including Waverly Health Center, Cedar

Valley Medical Specialists, Advanced Diagnostic Imaging, Wayson Family Chiropractic, Keller Chiropractic and all

providers not associated with the Wartburg Sports Medicine Team will bill your health insurance first and the

student-athlete second for any remaining balance(s).

Injury Assistance Program

Wartburg College recognizes that injuries occurring from participation in intercollegiate athletics can incur a

financial expense on student-athletes and their families. To assist in those cases, Wartburg offers injury assistance

funding to student-athletes that have incurred more than $1,000 in out-of-pocket expenses. For medical bills related

to athletic participation totaling up to $4,000; Wartburg College will reimburse 25% of your out-of-pocket expenses.

Please forward bills (not explanation of benefits) to:

Attn: Ryan Callahan

100 Wartburg Blvd

Waverly, IA 50677

Ryan.callahan@wartburg.edu

Fax: 319-352-8528

Wartburg College

Athletic Insurance Form

The following information and authorization must be completed for both parents even if they are divorced. If a parent is deceased please denote. PLEASE PRINT ALL INFORMATION REQUESTED ON THIS FORM. N/A or blank answers are not acceptable. This form must be completed before participation. All information will be kept confidential and used solely for the purpose of providing appropriate medical care for the student-athlete. Mail to: Dept. of Athletics-Athletic Training, 100 Wartburg Blvd, PO Box 1003 Waverly, IA 50677-0903

Student-Athlete _______________________________________________ Year in School_____________________

Date of Birth _________________ Sport(s) _________________________________________________________

Home Address __________________________________ City________________ State________ Zip____________

Home Phone (Area Code) ___________________________ Cell Phone (Area Code) __________________________

Father’s Name _______________________________________Cell Phone (Area Code)__________________________________

Address (If different than above)___________________________City_______________ State _______ Zip_______

Mother’s Name _______________________________________Cell Phone (Area Code) ________________________________

Address (If different than above) ____________________________City______________State______Zip_________

PRIMARY INSURANCE INFORMATION-PLEASE ATTACH A COPY OF BOTH SIDES OF YOUR INSURANCE CARD

Policy Holder’s Name _________________________________ Date of Birth _______________________________

Policy Holder’s Home Phone ___________________________ Policy Holder’s Cell Phone _____________________

Policy Holder’s Employer _________________________________________________________________________

Employer’s Address _________________________________ City __________________ State _____ Zip ________

Insurance Company __________________________________ Customer Service Phone # ____________________

Insurance Company Address ___________________________ City _______________ State ________ Zip _______

Group Number ________________ID/Member Number __________________ Other Numbers _______________

Insurance Type (Please Circle) HMO PPO UNRESTRICTED Is athlete covered when away from home? Y N

Primary Care Physician (PCP) _________________________________ Phone____________________________

Does your policy cover athletic related injuries? Y N Is referral required from PCP to see a specialist? Y N

SECONDARY INSURANCE INFORMATION (IF APPLICABLE)-Please copy information on back side of sheet

ACKNOWLEDGEMENT OF INSURANCE COVERAGE, ACKNOWLEDGEMENT OF RISK AND MEDICAL CONSENT

I/we understand it is the responsibility of the student athlete to carry health insurance coverage with a medical maximum of at least $75,000.* The student-athlete will not be allowed to practice or compete without proof of coverage. The student-athlete is responsible for all medical claims related to their participation in intercollegiate athletics at Wartburg College.

I/we understand the risks of injuries and losses that can occur as a result of participation in intercollegiate athletic activities and assume all risk.

I/we hereby further consent to Wartburg College obtaining whatever medical treatment and/or care as is deemed necessary by the College staff for the health and well-being of the student-athlete and I/we consent to have administered to the athlete any emergency medical or surgical treatment recommended by any licensed physician.

Parent/Guardian’s Signature: _____________________________________________ Date: ____________________________

Student Athlete Signature: _______________________________________________ Date: ____________________________

If the student-athlete is 18 years or older, a parent’s signature is not required for medical consent. However, it is highly recommended that the parent(s) read and sign the form to indicate that they acknowledge and understand the information provided on this page

***Include a front and back copy of your health insurance card with this form***

Wartburg College Sickle Cell Trait Disclosure and Waiver

The National Collegiate Athletic Association mandates that all NCAA student-athletes have knowledge of their sickle cell trait status, show proof of a prior test or a sign a waiver before the student-athlete participates in any intercollegiate athletics event, including strength and conditioning sessions, practices, competitions, etc.

Athletes should read through the “Sickle Cell Facts” below and complete the Disclosure portion if they have been tested or complete the waiver portion if they choose to waive testing. ONE of these sections must be completed in order for the student-athlete to be cleared for participation.

Sickle Cell Facts:

Sickle cell trait (SCT) is an inherited condition of the oxygen-carrying protein, hemoglobin, in the red blood cells

SCT is mostly 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.

SCT 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 types for 2-3 continuous minutes without a rest period, intense drills, and other spurts of exercise after prolonged conditioning exercises, and other extreme conditioning.

Common Signs and symptoms of sickle emergency include, but are not limited to: increased pain and weakness in 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.

Please complete one of the following portions and sign/date the bottom.

Sickle Cell Trait Disclosure 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, at the ______________________________________ Clinic. Please attach testing records to this form.

1. Sickle Cell Trait Positive Initial:

2. Sickle Cell Trait Negative Initial:

OR

SICKLE CELL TRAIT TESTING WAVIER

1. I am waiving my option to complete testing for Sickle Cell Trait Initial: ____________ I, ______________________________________________ , understand and acknowledge that the NCAA mandates 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 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 Wartburg College Sports Medicine Department.

I do not wish to undergo sickle cell trait testing and I voluntarily agree to release, discharge, indemnify and hold harmless the

State of Iowa, Wartburg College, it 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 Wartburg College Sports Medicine 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 wavier.

Student-Athlete Signature (if under 18, include parent/guardian signature) Date

Wartburg College Athletics

Release of Health Information

This authorizes the athletic trainers, team physicians and allied healthcare professionals representing Wartburg College to

release information concerning my medical status, medical condition, injuries, prognosis, diagnosis and related personally

identifiable health information to the parties listed below that participate in the provision of sports medicine services. This

information includes injuries or illnesses relevant to past, present or future participation in athletics at Wartburg College. I

understand the entities that receive the information may not be healthcare providers or covered by federal privacy regulations,

and the information described above may be re-disclosed publicly and the information will no longer be protected by those

regulations.

By initialing the following areas, I authorize the release of medical inform to that entity:

__ Sports Medicine Staff and Sports Medicine Assistants (This will allow athletic training staff, physicians, authorized allied health care personnel, and students participating in the

delivery of sports medicine services to assist and participate in the provision of health care to me while I am a student-

athlete.)

___ Media (This will allow college officials to advise the print, radio, television and other media of the nature, diagnosis, prognosis or

treatment concerning my medical condition and any injuries or illnesses so that they may report on it while I am a student-

athlete. Information released to the media will only be given in general terms unless previously approved by me.)

___ Professional Teams and Representatives (This will advise professional teams and their representatives of the nature, diagnosis, prognosis or treatment concerning my

medical condition and any injuries or illnesses so they may make decisions regarding my prospects as a professional athlete.)

___ Parents and/or Guardians (This will advise my parents/guardians of the nature, diagnosis, prognosis or treatment concerning my medical condition and

any injuries or illnesses so that they may assist me in making health care decisions while I am a student-athlete.)

___ Coaches and Athletics Staff (This will advise the coaches and athletics staff of the nature, diagnosis, prognosis or treatment concerning my medical condition

and any injuries or illnesses so that they may make decisions regarding my athletic ability and suitability to compete while I am

a student-athlete, I have the right to revoke this upon request on an individual case basis.)

___ Teammates (This will advise my teammates of the nature, diagnosis, prognosis or treatment concerning my medical condition and any

injuries or illnesses so they will be aware of limitations I may be under while I am a student-athlete.)

I understand Wartburg College will not receive compensation for its use/disclosure of the information. I understand I may refuse to

sign this authorization and refusal to sign will not affect my ability to obtain treatment. I may inspect or copy any information

used/disclosed under this authorization.

I understand I may revoke any or all parts of this authorization at any time by notifying in writing the Sports Medicine staff, and if I

do, it will not have any effect on actions the College took in reliance on this authorization prior to receiving the revocation. This

authorization expires six years from the date it is signed.

Student-Athlete Name:___________________________________________ Sport(s):____________________

Student-Athlete Signature:________________________________________ Date of Birth:________________

Wartburg College Athletics

Student-Athlete Assumption of Risk Student-Athlete:_____________________________________________ (Please print) Sport(s):____________________________________________________ Date of Birth: ___________________ Student-ID Number:_____________________________ Wartburg College endeavors to conduct its athletic programs in a manner consistent with the highest safety standards. However, Intercollegiate Athletics by their very nature involve the risk of personal injury which in some cases may be serious or even catastrophic. Therefore, as a willing participant in any college athletic program, there is personal assumption of risk on the part of student-athletes. Participating in Intercollegiate Athletics at Wartburg College including training and traveling may result in injury/illness, permanent physical or mental impairment, or even death. In the absence of gross negligence, I agree to assume all risks in participating in Intercollegiate Athletics that may cause me personal, or bodily injury, medical costs, death, and other consequential losses that may arise during my training, traveling, or participation. I understand that Wartburg College cannot be held responsible for any injuries or conditions which may be caused by the actions of third parties, other student-athletes, other teams, or myself, and agree not to litigate against the State of Iowa, Wartburg College, the Board of Trustees of Wartburg College, and all employees and agents of the Athletic Department, to include coaches, athletic trainers, strength/conditioning coaches, physicians, nurses, or administrators (collectively “Personnel”), from all claims related to any loss, injury, or expenses I may sustain. I declare and certify that to the best of my knowledge I am physically fit and have trained sufficiently for the level of activity required for intercollegiate competition. I understand Wartburg College and its Personnel cannot be held responsible for any pre-existing medical condition(s) I may have. Upon experiencing an injury/illness or change in my health status it is my responsibility to inform my Head Coach and Certified Athletic Trainer, and to adhere to the established protocols which include exercise rehabilitation, reconditioning, and reassessments before being allowed to return to full participation.

I HAVE READ, UNDERSTAND, AND VOLUNTARILY AGREE TO THE ABOVE STATEMENTS ______________________________________ _________________________ Student-Athlete’s Signature Date

______________________________________ _________________________ Parent’s Signature (required if S-A under 18 years of age) Date

ADHD MEDICAL EXCEPTIONS NOTIFICATION FORM

I , affirm that I have reviewed the NCAA Banned Substances list and the NCAA Medical Exceptions policy as it specifically pertains to the use of banned stimulant medications (e.g. Ritalin, Stattera, Adderall, Concerta, etc.) that are used to treat Attention Deficit Hyperactivity Disorder (ADHD), Attention Deficit Disorder (ADD) or 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, Stattera, Adderall, Concerta, etc.) that are used to treat ADHD or ADD, or like conditions.

Initial

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

I, the undersigned, do hereby affirm that I understand that I am to immediately notify a member of the Wartburg College Sports Medicine Department should I ever be prescribed the aforementioned stimulant medications and I must obtain and submit appropriate documentation from the prescribing physician in accordance with the NCAA Medical Exception Documentation Reporting Form. I further attest that I have had any and all questions regarding the NCAA ADHD Medical Exceptions Policy answered to my satisfaction. Student-Athlete Signature Date Athletic Trainer Signature Date

The NCAA banned substances list is available at: http://www.ncaa.org/2019-20-ncaa-banned-drugs or

on the Go-Knights.net Sports Medicine page under Forms.

Read the above NCAA Facts on concussions and print/sign/date below:

I,________________________________, have read the concussion educational materials and accept

the responsibility for reporting all my injuries and illnesses to the Wartburg College Sports Medicine

staff, including signs and symptoms of concussions.

_______________________________________ _______________________________ ________ (Printed Name) (Signature) (Date)

Wartburg College Concussion Statement

Please review the Wartburg College Athletics Institutional Drug Education and Testing policy on Go-Knights.net and

complete this consent form. The policy is on the Sports Medicine page under “Policies”.

Wartburg College

Drug Education & Testing Program Student-Athlete Consent

Form

I,____________________________________ hereby acknowledge that I have received a copy of, read and been given

the opportunity to ask questions regarding the Drug Education & Testing Program implemented for the Department of

Intercollegiate Athletics at Wartburg College. I understand the policies, procedures and my responsibilities as described in

such policy.

As a condition to my participation in intercollegiate athletics at Wartburg College, I consent to participate in the Drug Education

& Testing Program. I understand that my participation in this program includes the collection and testing of my urine or

saliva at various times during the

academic year for drugs, alcohol, and/or other banned substances.

I further consent to the release of the results of any drug test to the Director of Athletics or his/her designee, Assistant

Director of Athletics, my Head Coach, the Head Athletic Trainer and/or Assistant Athletic Trainers, Team Physician.,

Counseling Services, Appeals Committee and/or my parent(s) or guardian(s). I acknowledge and understand that a copy of

this consent form may be sent to my parent(s) or guardian(s) along with a copy of the Drug Education & Testing Program.

To the extent set forth in this document, I waive any privilege I may have in connection with the release of such

information.

I fully understand that the Wartburg College Drug Education & Testing Program is separate and distinct from the NCAA

drug-testing program. However, I also understand that sanctions may be imposed by Wartburg College under its Drug

Education & Testing Program upon a positive result under the NCAA drug-testing program.

Wartburg College, its officers, ·employees, and agents are hereby released from legal responsibility and/or liability for

the release of any information and/or record as authorized by this consent form. I fully and forever release and discharge

the aforementioned parties from any claims, demands, rights of action, or causes of action, present or future, whether

the same be known or unknown, anticipated .or unanticipated, resulting .from my participation in Wartburg College's

Drug Education & Testing Program including those claims, demands, rights of action, or causes of action arising out of any

positive result under such Drug Education & Testing Program.

Student-Athlete Name:____________________________________________

Student-Athlete Signature:________________________________________

Sport(s):________________________________________________________

Date of Birth:____________________________________________________

Student ID Number:_______________________________________________

Wartburg College Sports Medicine

Athlete Connection Profile

What is Athlete Connection?

Athlete Connection allows you to enter your demographic, medical and insurance information directly into the athletic

training room’s electronic medical records system. The process only takes a few minutes and is required before you

can begin receiving any athletic training room services for the 2015-2016 school year.

What do you need to do?

1. Go to https://athleteconnection.net

2. Use “Click here to register”

3. Enter account group 10736

4. Enter account code 3973974

5. Finish creating your own account

6. Once you have created your account you will be taken to your profile page. Please complete the information on

this page and click the Save Changes button when you are finished.

7. You can update your profile at any time by logging on to your account at https://athleteconnection.net

You will not be able to receive services from the athletic training room until this profile

is completed.