ࡱ> npm#` =bjbj *h5:::::::Nv"v"v"v"D"dNO2h*#:d#d#d#d#d#d#d#1111111$3h61: -d#d# - -1::d#d# 2... - :d#:d#1. -1..*1::v1d##  v"-NB1120O2J1,6c.@6v1v16:1(d#4&.6()9d#d#d#11. d#d#d#O2 - - - -NNN$r!NNNr!NNN::::::   WELLESLEY COLLEGE HEALTH UPDATE/PRE-PARTICIPATION DOCUMENTATION The following attachment contains all pertinent forms regarding health concerns while you are participating in athletics at Wellesley College. All forms must be signed and accurately completed to the best of your knowledge. Beginning in the fall of 2007, the NCAA passed legislation mandating that all returning student-athletes fill out a comprehensive updated medical questionnaire in addition to a screening of blood pressure and height/weight. All returning athletes will need to come to the athletic training room for this updated pre-participation examination (PPE)/review prior to any participation (practices) in intercollegiate athletics. Failure to comply with these regulations will result in the athlete being ruled ineligible and/or sanctions by the NCAA. Additionally, all athletes are required to show proof of medical insurance before participating in any physical activity. Do not forget to enclose a photocopy of both sides of your current medical insurance card! Families are urged to check with their insurance carriers to be certain that athletically related injuries and injuries while away from home will be covered. If the policy will not cover a dependent while away, or will not cover medical expenses in full, the college encourages families to consider the option of the college insurance policy as a secondary coverage. For more information on the colleges medical insurance option, go to  HYPERLINK "http://www.wellesley.edu/Health/Insurance/Koster_FAQ.pdf" http://www.wellesley.edu/Health/Insurance/Koster_FAQ.pdf. Please be assured that all medical and insurance information received are confidential. Once review is completed and passed, a list will be generated and given to your coaches saying you have been cleared for practices. This clearance includes having all of your materials turned in on time and any final clearance from the Health Center prior to competition. TEAM FORMS DUE FOR ALL ATHLETES BY 4PM ON PPE DATE/TIME Varsity crew Tuesday, September 2nd Wednesday, Sept. 3rd, 5pm/5:30pm Softball Wednesday, September 3rd Thursday, Sept. 4th at 6:15pm Lacrosse Wednesday, September 3rd Thursday, Sept. 4th at 6pm Swimming & diving Friday, September 5th Monday, Sept. 8th at 6pm Basketball Tuesday, September 30th Thursday, Oct. 2nd at 6pm Fencing Tuesday, September 30th Thursday, Oct. 2nd at 6:15pm Squash TBA Return forms in person to the athletic training room, B30 in the Keohane Sports Center basement, or send them via campus mail to: Jenn Grunzweig, Head Athletic Trainer Wellesley College, Keohane Sports Center, B30 106 Central Street Wellesley, MA 02481 If we do not have your forms by the date listed above, you WILL NOT PRACTICE on the first day! PLEASE CHECK THAT THE FOLLOWING ITEMS ARE COMPLETE AND INCLUDED PRIOR TO RETURNING YOUR INFORMATION. TWO completed copies of your Health Update/Pre-Participation Documentation for returning athletes are enclosed Enclosed is a photocopy of both sides of your current health insurance identification card. All forms are signed and complete! Questions? Contact  HYPERLINK "mailto:jgrunzwe@wellesley.edu" jgrunzwe@wellesley.edu Name: ____________________________ Sport: _____________ Grad year: _____ WELLESLEY COLLEGE HEALTH UPDATE/PRE-PARTICIPATION QUESTIONNAIRE FOR RETURNING ATHLETES This annual form and PPE/review must be completed and returned BEFORE the student-athlete will be permitted to participate in athletics at Wellesley College. The NCAA has passed legislation mandating that all returning student-athletes fill out a comprehensive updated medical questionnaire in addition to a screening of blood pressure and height/weight. All returning athletes will need to come to the athletic training room for this updated PPE prior to any participation in intercollegiate athletics. Remember, this is a health update only. It is not a full physical examination and should not be treated as such. Explain/dates: 1. Have you been hospitalized for any acute or chronic illness Y N ________________________ since the most recent medical update or evaluation? 2. Have you had a major injury (including concussion) since the Y N ________________________ most recent medical evaluation? 3. Are you currently ill in any way? Y N ________________________ 4. Are you currently injured in any way? Y N ________________________ 5. Are you currently under a physicians care for an injury/illness? Y N ________________________ 6. Do you have any allergies, including hypersensitivity to Y N ________________________ drugs, foods, and/or insect bites/stings? 7. Are you currently taking any medications or have any Y N ________________________ changes from your last medical evaluation or update? 8. Have you ever experienced a heat or cold related illness? Y N ________________________ 9. Have you experienced symptoms of asthma or bronchitis? Y N ________________________ 10. Have you lost function of a paired organ (eye, kidney, ovary, etc.)? Y N ________________________ 11. Do you experience cardiac symptoms or have a history Y N ________________________ of cardiac disease? 12. Is there a history of sudden death in a family member Y N ________________________ under the age of 50 from non-traumatic causes? 13. Have you experienced any irregularities in your Y N ________________________ menstrual cycle? 14. Do you have any history of an eating disorder? Y N ________________________ Please list dates/treatments 15. Do you know of, or do you believe there is any other health Y N ________________________ reason why you should not participate in the athletic program at Wellesley College? THIS SECTION TO BE FILLED OUT BY WELLESLEY COLLEGE MEDICAL STAFF Blood pressure: ___________________________ Height: ___________ Weight: ___________ BP #2 (date) ______________________________ BP #3 (date): ____________________________ LAT/MD/RN signature: ______________________________________ Date: ___________________________________ TO BE SIGNED AFTER YOUR REVIEW I, _____________________________________understand that having passed the physical examination or pre-participation examination does not necessarily mean that I am physically qualified to engage in athletics, but only that the evaluator did not find a medical reason to disqualify me at the time of said examination. Student-athlete: __________________________________________ Date: ___________________________________ DISCLAIMER Please read the following information carefully! The undersigned student-athlete: 1. Understands that participation in sport activity involves the potential for injury, which is inherent in all sports. The undersigned athlete acknowledges that even with the best coaching, use of the most advanced protective equipment and strict observance of the rules, injuries are still a possibility. On rare occasions these injuries can be so severe as to result in total disability, paralysis, or even death. I understand and accept these risks and will not hold Wellesley College responsible for any injuries sustained while participating in athletics. 2. Understands that they will be accountable to communicate changes in health status and/or injury conditions to the athletic training staff and team physicians. Student-athletes are expected to take responsibility for any lack of compliance with the treatment/rehabilitation plan, refusing treatment, and the impact that these decisions may have on their clearance for participation in athletics at Wellesley College. 3. Understands that having passed the physical examination or pre-participation examination does not necessarily mean that they are physically qualified to engage in athletics, but only that the evaluator did not find a medical reason to disqualify them at the time of said examination. 4. Certifies that the answers to the medical history form are correct and true. Athlete signature __________________________________________ Date: ______________ Athlete name (print) ________________________________________ Parent signature _________________________________________________ Date: ________________ (if under 18 years of age) RELEASE OF MEDICAL INFORMATION STATEMENT Please read information carefully! The Health Insurance Portability and Accountability Act of 1996, or HIPAA, was enacted by Congress to protect patients confidentiality and privacy regarding information pertaining to their medical condition. The law states that protected health information, or PHI, may only be released with the written consent of the patient. To provide the appropriate care to the athletes of Wellesley College, your personal information may need to be shared with any of the following persons: team physicians, health center clinicians, coaches, administration, parents, insurance personnel, or other allied health care providers. Be assured that your confidential medical information will be shared only when absolutely necessary for your optimal care. I, (athlete name) ________________________________ do hereby consent to the exchange of any medical information pertaining to my participation in athletics at Wellesley College between the Wellesley College athletic training staff and any medical personnel whose opinions are sought regarding such participation for as long as I attend Wellesley College. The athletic training staff and team physician are also authorized to disclose information regarding any injuries I might receive during the course of the season, as well as my general fitness to play, to my coaches or department administrators as needed. You have the right to withdraw this consent at any time, which must be done in writing. However, participation is contingent on the ability to release and share information with the above-mentioned parties. Athletes signature _________________________________________ Date: _______________ Parent/guardian signature ___________________________________ Date: _______________ (if under 18 years of age) ATHLETE EMERGENCY/HEALTH INSURANCE INFORMATION Name: ____________________________________ Sport: _____________________________________ Social security #: ______________________________ D.O.B. __________ Year of graduation: ________ Permanent address: _________________________________________________________________________ City: _______________________________________ State: ________ Zip code: ________________ Home telephone number: ______________________ Cell/dorm number: ____________________________ PARENT/GUARDIAN INFORMATION: Father/guardian name: _________________________ Mother/guardian name: _______________________ Address: ____________________________________ Address: ___________________________________ City: ___________________ State: _____ Zip: _____ City: ________________ State: _____ Zip: _______ Home phone: _________________________________ Home phone: _______________________________ Work phone: _________________________________ Work phone: ________________________________ Please designate an emergency contact: _________________________________________________________ INSURANCE INFORMATION (INCLUDE A PHOTOCOPY OF YOUR INSURANCE CARD) Primary coverage plan: Secondary coverage plan (if applicable) Insurance company: __________________________ Insurance company: _________________________ Policy #: ____________________________________ Policy #: ___________________________________ Group #: ________________ ID# ______________ Group #: _______________ ID# _______________ Insurance company address:  Insurance company address: ___________________________________________ __________________________________________ ___________________________________________ __________________________________________ Phone number: ______________________________ Phone number: _____________________________ Subscriber name: ____________________________ Subscriber name: ___________________________ Employer : ____________________________ Employer: _____________________________ Is primary plan an HMO? Yes No If yes: primary care physician (PCP) Name: ____________________________________ Phone: ____________________________________ Is PCP visit/approval required for referral? Yes No Is prior approval required for surgery? Yes No *Families are urged to check with their insurance carriers to be certain that athletically related injuries and injuries while away from home will be covered. If the policy will not cover a dependent while away, or will not cover medical expenses in full, the college encourages families to consider the option of the college insurance policy as a secondary coverage. For more information on the colleges medical insurance option, please go to  HYPERLINK "http://www.wellesley.edu/Health/Insurance/Koster_FAQ.pdf" http://www.wellesley.edu/Health/Insurance/Koster_FAQ.pdf. Release to treat: By signing within, I hereby authorize the athletic training staff, team physicians, and medical consultants to provide any and all care deemed necessary for any specific injury or condition and to release any medical or insurance information as necessary. 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