Mary Baldwin College



Mary Baldwin University

Athletic Medical Eligibility Forms and Pre-Participation Physical Exam

All athletes must fill out the following forms and have a pre-participation physical in order to participate in athletics. To be accepted, the pre-participation physicals must be conducted after July 1. All athletes must have the forms completed and returned by mail no later than the first Friday in August. Medical eligibility must be renewed every academic year. Please use the checklist below:

_____ Step 1 Complete the Health History Form on page 2 prior to obtaining your physical examination. You MUST present the Health History Form to the physician for his/her signature. Be sure to indicate your primary care doctor’s name and phone number as requested if it is different than the medical provider completing your physical exam in step 4.

_____ Step 2a Complete the “Insurance Certification Form” on page 3. This form must be completed in full and requires detailed insurance information. Any changes to the information provided must be reported to the Athletic Trainer immediately. Additional insurance information can be found on page 8.

_____ Step 2b Photocopies of both the front and back of the policy holder’s wallet sized insurance information must be provided with this package. If no such documentation exists, a copy of the policy verification must be substituted. A hand written or typed paper with the policy number and insurance company is not acceptable.

_____ Step 3 Complete the Emergency Notification, Medical Alerts, Release of Medical Information and Permission to treat Minor sections on page 4. The information provided in steps 2 and 3 will travel with teams to away events in the case of emergencies.

_____ Step 4 Provide the examining physician, physician’s assistant or nurse practitioner with your completed Health History Form (Step 1) for review and signature at the time of the exam. The Physician’s Exam should clearly indicate your medical clearance status for all the sports that you expect to participate in during the course of the academic year. Those sports should be listed at the top of the Health History Questionnaire in Step 1. Pease ask your medical exam provider to clearly document their name, address and phone number.

_____ Step 5 Please read the Risk Awareness, ADHD medications and Concussion statements on page 6 and sign where necessary.

_____ Step 6 This separate form, Sickle Cell Trait Testing, MUST be filled out by a physician (page7). This is a new NCAA requirement. Please make it clear to the physician that this is mandatory for participation in the sports program. You may be able to obtain this information from the hospital at which you were born.

FIRST YEAR STUDENTS – Mary Baldwin requires you to fill out a Mary Baldwin Health Record Form. This is separate from the athletic forms. The college only requires this on your entry into Mary Baldwin. The athletic physical is required each year that you will be participating in athletics.

Address any questions about this form to your coach or: Lynda Alanko

Sports Information Director

Mary Baldwin University

lalanko@marybaldwin.edu

Step 1: Mary Baldwin Athletic Pre-Participation Evaluation

Last Name: _______________________ First Name ____________ M.I. _________ School yr _______

Date of Birth: Month_______ Day _____ Year _______

Sport 1 ____________________ Sport 2 ______________________ Sport 3 ______________________

Explain “Yes” answers below: Yes No

1. Have you ever been hospitalized? ( (

Have you ever had surgery? ( (

2. Are you presently taking any medications or pills? (list on page 4 & ADHD page 6) ( (

3. Do you have any allergies? (medications, bee stings or food, list on page 4) ( (

4. Have you ever passed out during exercise? (Please see Sickle Cell Trait page 6) ( (

Have you ever been dizzy during or after exercise? ( (

Have you ever had chest pain during or after exercise? ( (

Do you tire more quickly than your friends during exercise? ( (

Have you ever had high blood pressure? ( (

Have you ever been told you have a heart murmur? ( (

Have you have had racing of your heart or skipped heartbeats? ( (

Has anyone in your family died of heart problems before the age of 50? ( (

5. Do you have any skin problems? (itching, rashes, acne) ( (

6. Have you ever had a head injury? ( (

Have you ever been knocked out or unconscious? ( (

Have you ever had a seizure? ( (

Have you ever had a burner, stinger or pinched nerve? ( (

7. Have you ever had heat cramps or muscle cramps? ( (

Have you ever passed out from the heat? ( (

8. Do you have trouble breathing or do you cough during or after activity? ( (

9. Do you use any special equipment? (braces, mouth guard, etc) ( (

10. Do you have any problems with your eyes or vision? ( (

Do you wear glasses or contact lenses or protective eye-wear? ( (

11. Have you ever sprained, strained, dislocated, fractured or had swelling in joints or bones? ( (

( Head (Shoulder (Thigh (Neck (Elbow (Knee (Chest

( Forearm (Shin/Calf (Back (Wrist (Ankle (Hip (Hand (Foot

12. Have you ever any other medical problems? (Infectious mononucleosis, diabetes, etc) ( (

13. Have you had a medical problem or injury since your last evaluation? ( (

14. When was your last tetanus shot?

15. When was your first menstrual period?

When was your last menstrual period?

What was your longest time between your periods last year?

EXPLAIN “YES” Answers Here

I hereby state that answers to the questions above are correct and accurate.

Signature of athlete: ________________________________________________________ Date: ______________________

Name of primary Physician: _________________________________________________ Phone: ____________________

I have reviewed this questionnaire.

Signature of person completing Pre-Participation Physical______________________________ Date: ______________

Step 2a Mary Baldwin Athletic Training / NCAA Insurance Certification

This form must be on file prior to any student being allowed to participate in team sports.

Name of Athlete (printed) ______________________________________________________________

Date of Birth _____/_____/_____

Parent/Guardian Name(s) (printed) _______________________________________________________

Address ____________________________ City __________________ State ___ Zip ______________

Phone Home _______________________ Cell _____________________ Work ___________________

Policy Holder’s Name (print) ____________________________________________________________

Relationship to Student-Athlete (SA) ___________________________________________________

Address (if different from Parent/ Guardian) ________________________________________________

City __________________ State ______ Zip __________ Phone Home ________________________

Cell _________________________________ Work _________________________________________

Insurance Company’s Full Name _________________________________________________________

Insurance Company’s Address __________________________________________________________

City _________________________ State ______________________ Zip _______________________

Group ________________________________ ID# __________________________________________

Effective Date of Policy ________________________ Expiration Date __________________________

Policy Deductible _____________________________ Policy Co-Pay ___________________________

Primary Care Physician’s Printed Name ____________________________ Office Phone ___________

I have read the Mary Baldwin/NCAA Insurance Statement (page 7) and I am aware of my financial responsibilities in the event of an athletic related injury when the SA is conducting themselves as a member of the Mary Baldwin Athletics Department. My signature below indicates that my policy meets or exceeds the minimum coverage required by the NCAA and I will report any change in coverage to Mary Baldwin’s Athletic Training Staff.

Parent/Guardian Signature ____________________________________ Date _________________

SA Signature, if policy holder _________________________________ Date ________________

STEP 2 b: Please provide a photo-copy of insurance card front and back.

Step 3 EMERGENCY NOTIFICATION

Athlete’s Name _________________________________

Date of Birth ______/_______/______

Athlete’s Primary Address (Campus/Local) Athlete’s Secondary Address (Home)

Dorm & Room ______________/________ Street ______________________________

Street Address (off campus) _____________ City/State/Zip ________________________

City/State/Zip ________________________ ____________________________________

Phone# Campus _________________ Cell ______________ Home ____________________________

Primary Emergency Contact: (parent/guardian) Secondary Emergency Contact:

Name ____________________________________ Name ______________________________

Street Address _____________________________ Street Address _______________________

City/State/Zip ______________________________ City/State/Zip ________________________

Home Phone _______________________________ Home Phone _________________________

Work Phone _____________ Cell ______________ Work Phone __________ Cell ___________

Relationship _______________________________ Relationship _________________________

MEDICAL ALERTS

Please list any medical conditions, allergies, and medications that medical personnel should be aware of.

Alerts ______________________________________________________________________________

Allergies ___________________________________ Drug Allergies ____________________________

Medicines taken regularly ________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________

If you take medication for ADHD refer to Page 6 for additional information on NCAA requirements.

CONSENT AUTHORIZATION AND AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

I authorize the release of my medical records as may be requested by the certified staff members of Mary Baldwin’s Athletic Training Staff and/or the Director of Mary Baldwin Health Services. Information from these records will be used to provide appropriate care and assist in medical decisions. All information will be considered confidential. All such records will be maintained in the athlete’s permanent medical record files located in the Athletic Trainer’s office and the Director of Health Services.

___ Yes, I agree to release needed records pertaining to my athletic participation.

___ No, I wish my records to remain confidential with my physician.

Signature of Athlete ______________________________________ Date ______________________

PERMISSION TO TREAT MINOR

Student-Athletes under the age of 18 must have parent/guardian permission to receive medical care.

I give permission to the certified athletic trainer and medical staff of Mary Baldwin as well as certified athletic trainers at host institutions to evaluate and treat my daughter. Every effort will be made to contact you and/or the person listed above on the Emergency Notification form prior to any medical services being rendered in an off-campus setting; however, emergency care will be provided as needed.

_________________________________________ _______________________ _______________

Signature of parent (if child is a minor) Relationship Date

Step 4 Athletic Pre-Participation Physical Evaluation

Name ____________________________ Age ______ Date of Birth ___________________________

Height _______ Weight _______ BP(R) _______ or (L) _______ Pulse _______ Pupils ____________

Vision: R 20/_____ L 20/_____ Corrected: Y N Any missing or nonfunctioning organs? __________

Please list any abnormal Findings

Lungs/Chest Normal ____________________________________________________________

Heart Normal ____________________________________________________________

Pulses Normal ____________________________________________________________

Skin Normal ____________________________________________________________

Eyes/Ears Normal ____________________________________________________________

Neck/Nodes Normal ___________________________________________________________

Thyroid Normal ____________________________________________________________

Abdominal Normal ____________________________________________________________

Genitalia Normal ____________________________________________________________

Musculoskeletal Normal ____________________________________________________________

Shoulder Normal ____________________________________________________________

Elbow Normal ____________________________________________________________

Wrist/Hands Normal ____________________________________________________________

Back Normal ____________________________________________________________

Knees Normal ____________________________________________________________

Ankles/Feet Normal ____________________________________________________________

Reflexes Normal ____________________________________________________________

Other ______________________________________________________________________________

Clearance: ( A. Cleared for all Sports

( B. Cleared after completing evaluation/rehabilitation

( C. Not cleared for: □ Collision □ Contact □ Non-contact

Comments: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Date of Examination ______________ Printed name of Examiner __________________________

Signature of Examiner _______________________________________ (MD, DO, PA, NP)

Please note that the examiners signature is required on the Health History Questionnaire on Page 2.

Street Address _______________________ City __________________ State _______ Zip __________

Office Phone Number ________________________

Step 5

a. Risk Awareness Statement

Mary Baldwin seeks to provide a safe intercollegiate athletic program. Despite requiring pre-participation examinations and utilizing the services of a certified athletic trainer, accidents and injuries do occur. Your signature below indicates that you are aware that the participation in and travel to athletic events has an inherent risk involved and that you accept this risk. (This is NOT a liability waiver)

Signature: ___________________________________________ Date: _____________________________

b. ADHD Medication Statement

The NCAA requires documentation of stimulant medication commonly prescribed for Attention Deficit Hyperactivity Disorder (ADHD). Many medications used to treat this disorder are among substances banned by the NCAA. Institutions must present documentation that these medications have been prescribed by a physician and also have been supported by a clinical assessment for education and health reasons. Go to health-safety for more information on Banned Drugs and Medical Exceptions Policy for further explanation. Your medications should be listed on page 2 within the Health History when answering yes to question #2 and also listed on page 3 under Medical Alerts – Medications. Please provide the following:

Prescribing Physician ____________________________________________________________________

Physician Address ____________________________________________________________________

Phone and Fax ___________________/_____________________

c. Concussion Statement

Your signature below indicates that you have read the NCAA information found at health-safety concerning concussion symptoms and health concerns. Addition information can be obtained from the athletic trainer. By signing below you agree that you will notify your coach or the athletic trainer that you suspect you may be suffering from the symptoms of a concussion. This also means you will notify the athletic training staff at away events if you believe you may be suffering concussion symptoms. The athletic trainer will also test you for a base-line score prior to the season which will allow the athletic trainer better monitor your recovery.

Signature of Athlete: _____________________________________ Date: __________________________

Step 6

MARY BALDWIN UNIVERSITY

Sickle Cell Trait Testing

Sickle cell trait is the inheritance of one gene for sickle hemoglobin and one for normal hemoglobin. During intense exercise or extensive exertion, the sickle hemoglobin can change shape of the red blood cells from round to quarter-moon or “sickle.” This change, exertional sickling, can pose a greave risk of some athletes. In the past seven years, exertional sickling has killed nine athletes, ages 12 through 19.

Starting in the fall season of 2014 all NCAA student-athletes must have knowledge of their sickle cell trait status. Although all people born in the United States are tested at birth, few student-athletes know whether they are positive or negative for the trait. When you schedule your physical for the upcoming sports season, be sure that your doctor signs this form stating your sickle cell status. Without this information you will not be able to participate in athletics at Mary Baldwin.

________________________________________________________________________

The Form below Must be Completed and Signed by a Physician

Student Athlete’s Full Legal Name: __________________________________________

Date of Sickle Cell Test: ___________________________________________________

Results of the Sickle Cell Testing: Positive _______ Negative _______

Are there any reasons why this person should not be allowed to participate in Division III

Sports based on the results of this test? ____________ If so, please explain below: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Physician’s Signature: ___________________________________

Physicians Printed Name: ________________________________ Date: _____________

Student-Athlete’s Signature: ______________________________

Parent’s Signature (If Student Athlete is a Minor) _______________________________

MEDICAL & HEALTH INSURANCE REQUIREMENTS

MARY BALDWIN UNIVERSITY

If you have any questions regarding these requirements please contact your coach at:

Mary Baldwin University

P.O. Box 1500

Staunton, VA 24402

Why do athletes need insurance coverage? Mary Baldwin athletics assumes no responsibility whatsoever for the payment of medical expenses resulting from injuries that occur while participating in intercollegiate athletics at Mary Baldwin. Mary Baldwin must comply with NCAA membership requirements regarding minimum health insurance coverage for student-athletes (SAs). All NCAA and therefore Mary Baldwin SAs must provide evidence of health insurance that includes a minimum of $90,000 coverage for all athletic related injuries.

Insurance Verification/Certification

Certification of this insurance is required prior to any participation in practices or competition. No Mary Baldwin athlete will be allowed to participate in any way until such evidence of current insurance coverage is on file with the Mary Baldwin Athletic Training Department. The “Insurance Certification” form along with a photocopy of both sides of the policy holder’s insurance card must be on file before a SA can participate. This form can be found as Step 2 a. and b. of the Medical Eligibility forms packet.

Out-of-Network & HMO Coverage in Staunton, VA

If you have local network or HMO coverage please ask your insurance carrier to provide you with the details concerning out-of-network care and/or “guest policy” privileges in Staunton, VA. Athletes are often delayed in obtaining medical care as they are searching for the details of their insurance coverage. Questions you need your insurance provider to answer are:

1. Who are approved providers for our plan in the Staunton area?

2. What, if any, extra expense will I incur because my child is now “out-of-network?

NCAA Catastrophic Insurance

The NCAA’s Catastrophic Injury Insurance Program will cover student-athletes who are catastrophically injured while participating in covered inter-collegiate athletic activity (subject to all policy terms and conditions). This catastrophic policy has a $90,000 deductable and does not qualify as basic coverage required for participation at Mary Baldwin. It is supplemental coverage in the event of a catastrophic injury. More information can be found on the NCAA’s web-site at .

Additional Coverage

Although Mary Baldwin does not offer a policy which parents or students can purchase through the college/university there are companies that offer coverage for college students and athletes. One company is Markel at . I will post other companies as information becomes available.

Please be sure your insurance policy will be accepted in the Staunton, Virginia area. It is important that our athletes receive timely and professional care. We have had a few instances where an athlete had to postpone treatment or had to travel great distances because their insurance would not cover them out-of-network.

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