Judson University Athletic Training Student-Athlete Information Check List

These document forms must be used and returned. NO other forms will be

accepted.

Only physicals performed by MD, DO, PA or nurse practitioners (NP) will be

accepted. Physicals given from a chiropractor will not be accepted.

All paperwork must be returned to the athletic trainer prior to the first day of

practice/conditioning, which includes off season training.

Athlete will NOT be permitted to participate unless this complete package is turned in and forms completed online

Check List

*______ Athletic Physical Examination Form

*______ Emergency Medical Information

*______ Insurance Information Form*______ Copy of Insurance Card (Front & Back) *______ Medical History Form*______ Assumption of Risk and Informed Consent

*______ Sickle Cell Trait Documentation

______ Receipt & Viewing of Sickle Cell Trait Information Form ______ Receipt & Viewing of Concussion Fact Sheet ______ Completed the 3 online form from the Health Center website links as listed below

Pre Entrance Medical Form / Immunization Requirements / Health Insurance Form(click on the Link/Button and complete the form and hit submit at the bottom of the page)

https://myjudson.judsonu.edu/ICS/Wellness/Health_Services.jnz

Please scan and email all completed paperwork marked with (*) back to your coach and direct any questions to your head coach.

Judson University 1151 N State St.

Elgin, IL 60123

JUDSON UNIVERSITY ATHLETIC TRAINING

EMERGENCY MEDICAL INFORMATION

NAME: ________________________________ DATE OF BIRTH: ________________________________

SCHOOL YEAR ( 2019-2020 ) YEAR IN SCHOOL: FR SOPH JR SR (Circle 1)

SPORT(s): _____________________________________________________________________________

JUDSON E-MAIL: _______________________________________________________________________

HOME ADDRESS: ______________________________________________________________________

CITY, STATE, ZIP: _______________________________________________________________________

CELL PHONE: __________________________________________________________________________

EMERGENCY CONTACT

MEDICAL INFORMATION

ALLERGIES: ___________________________________________________________________________

MEDICATIONS: ________________________________________________________________________

PRIMARY

NAME: ____________________________________

RELATION: _________________________________

HOME PHONE: ______________________________

CELL PHONE: _______________________________

WORK PHONE*: _____________________________

SECONDARY

NAME: ____________________________________

RELATION: _________________________________

HOME PHONE: ______________________________

CELL PHONE: _______________________________

WORK PHONE*: _____________________________

JUDSON UNIVERSITY ATHLETIC TRAINING

INSURANCE INFORMATION

Do you carry Primary Insurance? ____Yes ____No

Is your primary insurance the student plan offered at Judson University? ____Yes ____No

NAME OF INSURANCE COMPANY: _________________________________________________________

TYPE OF INSURANCE (CIRCLE) HMO PPO Other: _________________________________

POLICY NUMBER: ______________________________________________________________________

GROUP NUMBER: ______________________________________________________________________

INSURANCE COMPANY PHONE NUMBER: ___________________________________________________

POLICY HOLDER: _______________________________________________________________________

RELATIONSHIP TO ATHLETE: ______________________________________________________________

POLICY HOLDER DATE OF BIRTH: __________________________________________________________

POLICY HOLDER EMPLOYEER: _____________________________________________________________

POLICY HOLDER EMPLOYEER PHONE NUMBER: ______________________________________________

***YOU MUST INCLUDE A READABLE COPY OF THE FRONT AND BACK OF YOUR INSURANCE CARD ***

JUDSON UNIVERSITY ATHLETIC TRAINING

ASSUMPTION OF RISK AND INFORMED CONSENT FORMS

(Year: 2019-2020) Please read, sign and return the following consent form. If you are under the age of 18, you must also have your parents sign. If you choose to refuse to sign this form, please write

“Refuse to Sign”, date and print your name and/or your parents’ names.

Name: ______________________________________________________

Sport(s): _____________________________________________________

ASSUMPTION OF RISK

I am aware that by playing, or practicing to play, any sport can be dangerous, involving many risks of

injury. I understand that the dangers and risks of participating in the above sport(s) may include, but are

not limited to: serious bodily injury, which may cause loss of limb, loss of sensory function (i.e. sight,

hearing, etc.), permanent physical impairment, paralysis, or even death. With this understanding I

assume the risk of participation in the above sport(s) at Judson University. Because of the dangers of

participating in the above-mentioned sport(s), I recognize the importance of following Judson

University’s Team Physicians’, Certified Athletic Trainers’, and Coaches’ instructions concerning playing

techniques, conditioning, rehabilitation, and team rules. I agree to report all injuries to a Judson

University Certified Athletic Trainer and to follow the recommendations of the Team Physician and/or

Certified Athletic Trainers regarding participation. I understand that my personal medical information

may be discussed amongst the Judson University Wellness Center, Team Physicians, Certified Athletic

Trainers, and Coaches, as they deem necessary.

Student-Athlete Signature: ___________________________________ Date: ___________________

Parent or Guardian Signature (if athlete is under 18 years of age): ______________________________

CONSENT TO TREAT

The Judson University Medical Staff, including Certified Athletic Trainers, Team Physicians and others

deemed necessary, have my permission to seek and provide necessary care and treatment for any

illness or injury that may occur during participation in intercollegiate athletic practices, games, and

conditioning. This permission remains in effect until June 31, 2020.

Student-Athlete Signature: ___________________________________ Date: ___________________

Parent or Guardian Signature (if athlete is under 18 years of age): ______________________________

JUDSON UNIVERSITY ATHLETIC TRAINING

MEDICAL HISTORY

Name: ______________________________________ Date of Birth: ___________________________

Sport(s): ______________________________________________________________________________

Instructions: When reply is yes, give date of injury and treatment. Please indicate the anatomical site of

injury, left or right, and any other information you consider important. Circle the appropriate response.

GENERAL MEDICAL YES NO Have you ever been advised by a medical doctor not to participate in sports?

For what reason?

YES NO Have you had any surgeries in the past two years? If yes, identify the anatomical site, surgery, and date.

YES NO Are you currently on prescribed medications? If yes, please indicate name of the medication and reason it is prescribed.

YES NO

Do you have any known allergies? Please list

Are you allergic to any medications? (i.e. aspirin, sulfa, etc.) If yes, please indicate name of the medication.

YES NO Are you currently taking any medications? Please list

YES NO Do you take any supplements? Please list.

YES NO Have you ever had heat exhaustion, heat stroke, or hyperventilation? If yes, please indicate which type of heat illness and when it occurred.

YES NO Have you ever had an organ removed? If yes, which organ?

YES NO Have you been told you have a hernia? If yes, was it repaired?

YES NO Are you currently under the care of a physician? If yes, for what injury/medical condition?

HEAD AND NECK INJURIES YES NO Have you ever had a serious neck injury? Please list injury and dates of injury.

YES NO Have you ever experienced a concussion or been “knocked out”, or dazed during the past four years? If yes, please give dates.

If answer to above is yes, did a physician have you stay overnight in a hospital? Please list dates and details.

EYE AND DENTAL YES NO Do you have any eye problems? Please describe.

YES NO Do you wear eye glasses and/or contact lenses? If yes, do you wear them for athletics?

YES NO Do you wear dentures? If yes, CIRCLE appropriate denture: Permanent bridge, Permanent crown of jacket, Removable partial or Full plate

BONE AND JOINT YES NO Have you had a fracture in the past four years? If answer is yes, indicate the site of fracture and date.

YES NO Have you ever had a shoulder injury? If yes, what and when was the injury?

YES NO Have you ever been advised to have a surgery to correct a shoulder condition? If yes, what was the surgical repair and when was the surgery completed?

YES NO Have you ever experienced a severe sprain, dislocation or fracture? If yes, give date and amount of limitation?

YES NO Have you ever had an injury to your back? If yes, give the date and nature of the injury?

If yes, did you seek the advice or care of a physician? What was the therapy and is it completed?

YES NO Do you experience back pain? If yes, please indicate frequency with which you experience pain by underscoring the following: very seldom, frequently, only with exercise.

YES NO Have you ever been told that you injured the ligaments of either knee? Please give dates.

YES NO Have you ever been advised to have surgery to a knee to correct a condition? Please give dates

YES NO Have you ever experienced a severe sprain of either ankle during the past four years? Please give dates.

YES NO Do you have a pin, screw, or plate somewhere in your body as a result of bone or joint surgery? If yes, indicate anatomical site and date of surgery.

YES NO Do you have limited movement in any of your joints? Please explain.

YES NO Have you ever been told you have torn muscle/s? Please explain.

DISEASE AND ILLNESS YES NO Have you been diagnosed with ADHD? Are you currently on medication for ADHD? If yes, which medication?

YES NO Have you ever experienced a seizure or been informed that you might have a seizure disorder? If yes, please provide the date/s.

YES NO Have you had hepatitis during the past three years?

YES NO Have you been treated for infectious mononucleosis, pneumonia, or any other infectious diseases during the past 12 months? If yes, please provide the date/s of illness.

YES NO Have you ever been treated for diabetes? If yes, please provide your current management plan.

YES NO Have you ever been treated or informed by a physician that you have had rheumatic fever?

YES NO Have you ever been told you have a heart murmur, mitral valve prolapse or increased systemic blood pressure? Please circle. Please explain any treatment for the condition.

YES NO Have you had any illness requiring bed rest of one week or longer during the past year? Please give date and explain.

YES NO Do you have asthma?

If yes, do you use an inhaler or rescue inhaler? Please list the name of the medication.

YES NO Have you ever fainted during exercise? Please explain.

YES NO Have you ever experienced chest pain or discomfort during exercise?

YES NO Have you ever experienced excessive, unexpected, and unexplained shortness of breath or fatigue associated with exercise?

YES NO Do you have a family history of premature death (sudden or otherwise), or significant disability from cardiovascular disease in close relatives younger than 50 years old? If yes, which family members?

YES NO Do you have a family history of the occurrence of the following conditions: Hypertrophic cardiomyopathy, dilated cardiomyopathy, long QT syndrome, Marfan Syndrome, clinically important arrhythmias? If yes, which family members?

YES NO Have you received a tetanus shot in the last 10 years? If yes, please provide the date.

FEMALE ATHLETES YES NO How old were you when your menstrual period started?

YES NO Is your menstrual cycle 28 days long? If not, please indicate length of cycle: Please give approximate length of your monthly menstrual period.

YES NO Do you have menstrual cramps which are severe enough to require medication?

YES NO Within the last 12 months have you had any stress fractures, menstrual irregularity, loss of periods, significant weight change or weight concerns? Please explain:

Additional Medical History Write in medical problems, injuries, or conditions that you have had and are not included in the previous questionnaire.

Please use additional sheet(s) if necessary

I, the undersigned, hereby acknowledge, affirm and represent that all above statements are true and

accurate to the best of my knowledge, and that no answers or information have been withheld. If any

information and/or statements are false and/or have been omitted in reference to my past medical

history, I fully understand that Judson University disclaims liability, and will not be held liable for any

injuries and/or illness not noted and has the ability to cancel your athletic scholarship as a result of false statements.

Signature of Student-Athlete Date

Signature of Parent/Guardian (if student-athlete is under 18) Date

Judson University Sickle Cell Trait Documentation

About Sickle Cell Trait (SCT)

Sickle cell disease is a serious blood disorder that causes acute pain, severe anemia, infections, and

vascular blockages that can lead to widespread organ damage and death.

Individuals who are at a high risk of SCT are those with ancestry from Africa, South or Central America,

India, Saudi Arabia, Caribbean, and Mediterranean countries.

Sickle cell trait is usually benign, but during intense, sustained exercise, hypoxia (lack of oxygen) in the

muscles may cause sickling of red blood cells (red blood cells changing from a normal disc shape to a

crescent or “sickle” shape), which can accumulate in the bloodstream, blocking normal blood flow to

tissues and muscles.

Athletes with SCT should not be excluded from participation as precautions can be put into place.

Sickle Cell Trait (SCT) Testing Compliance Form

Compliance Statement The NAIA does NOT mandate NAIA student-athletes to have knowledge of their SCT status prior to participation in intercollegiate athletic sanctioned events. The NAIA and Judson University HIGHLY recommend that all student-athletes have knowledge of their Sickle Cell Trait (SCT) status prior to participation in any intercollegiate athletic events, including tryouts, practice, competition, and strength and conditioning sessions. If you choose to waive testing, you are acknowledging that you understand the importance of testing, have declined and release Judson University from any liability related to declining the test.

SCT test results are considered protected health information and will be kept confidential. However, Judson University Wellness Center and Judson University Athletic Training staff will need to be aware of your SCT status in order to provide appropriate care for you during practice, competition and conditioning. Your written consent will be requested before any protected health information is released to any other parties.

If you are under 18 years of age, a parent or guardian must sign this form.

Name of Student Athlete (Print Please)

_______ I have been tested for SCT and have included a copy of my test results, signed and dated by a physician.

_______ I do not wish to have SCT testing performed. I understand the information regarding SCT and the

recommendation from the NAIA and Judson University that SCT testing be performed on all student-athletes, but choose not to participate, waive the option to be tested and release Judson University, its officers, employees and agents from any and all costs, liabilities, expenses, claims, demands, or causes of action on account of any loss or personal injury that might result from the non-compliance with the mandate from any liability related to declining the test.

Signature of Student-Athlete Date

Signature of Parent/Guardian (if student-athlete is under 18) Date

athletic training form

athletics

JUDSON UNIVERSITY PHYSICAL EXAMINATION FOR ATHLETICS

Last Name First Name MI Sex: M F

Date of Birth (mm/dd/yy) Age

Height (inches) Weight (Lbs.)

B/P /

Pulse

Resp.

Vision Acuity: L R

Corrected Y/ N Pupils equal Y/N

Last Tetanus Shot

Sickle Cell Date and Result

Marfan’s syndrome stigmata No Yes

Heart Rhythm: Regular Irregular

Heart Murmur: No Yes Standing Sitting MUSCULOSKELETAL NORMAL ABNORMAL FINDINGS INITALSNeck SpineShoulder/arm Elbow/forearm Wrist/hand Back Hip/thigh Knee Ankle/Leg Foot

MEDICAL NORMAL ABNORMAL FINDINGS INITALSEars/eyes/nose/throat ChestLymph Nodes HeartPulse LungsAbdomen/Pelvis Genitalia (Males only) SkinOtherComments or Assessments

CLEARANCE IS: Without Restriction Pending due to

Deferred due to

PRACTICE STATUS: Full Go Non Contact-Strenuous Non Contact- Non Strenuous Participate As Able No Practice

Physician Name Printed:

Phone Number:

Physician Name Signed:

Date:

Judson un ivers ityathleticsathletic training form

JUDSON UNIVERSITY PHYSICAL EXAMINATION FOR ATHLETICS

Last Name __________________________ First Name _________________________ MI _______ Sex: M F

Date of Birth ______________(mm/dd/yy) Age ______ Height __________(inches) Weight __________(Lbs.)

B/P _____/_____ Pulse _____ Resp. _____ Vision Acuity: L ____ R ____ Corrected Y/ N Pupils equal Y/N

Last Tetanus Shot ___________________ Sickle Cell Date and Result ____________________

Marfan’s syndrome stigmata No Yes ________________________________________

Heart Rhythm: Regular Irregular ___________________________________________

Heart Murmur: No Yes Standing Sitting _____________________________________

MUSCULOSKELETAL NORMAL ABNORMAL FINDINGS INITALS

Neck

Spine

Shoulder/arm

Elbow/forearm

Wrist/hand

Back

Hip/thigh

Knee

Ankle/Leg

Foot

MEDICAL NORMAL ABNORMAL FINDINGS INITALS

Ears/eyes/nose/throat

Chest

Lymph Nodes

Heart

Pulse

Lungs

Abdomen/Pelvis

Genitalia (Males only)

Skin

Other

Comments or Assessments _____________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

CLEARANCE IS: Without Restriction Pending due to ______________________ Deferred due to ______________________

PRACTICE STATUS: Full Go Non Contact-Strenuous Non Contact- Non Strenuous Participate As Able No Practice

Physician Name Printed: _________________________________________________ Phone Number: _____________________

Physician Name Signed: __________________________________________________ Date: ___________________

Medical Compliance Requirements IMMUNIZATIONS REQUIRED BY THE STATE OF ILLINOIS

(Take to Doctor's Appointment)

Required: TD (Tetanus/Diphtheria) Must be within 10 years of the first day of classes for the Fall semester.

Required: MMR (Measles/Mumps/Rubella) Two does required at least one month apart AND after 12 months of age

Or date of lab test proving immunity to Measles/Mumps/Rubella Date

Required: MENINGOCOCCAL Vaccine Two does required at least one month apart AND after 12 months of age