Austin College Athletic Training To: Austin College Student-Athletes and Parents From: Amanda Parsley Head Athletic Trainer Austin College Subject: Pre-Season Paperwork Attached is the medical paper work you will need to have completed before you can participate in any athletic activities for the 2010-2011 athletic year. You must have a physical within 3 months of the start of your season to compete. In your packet is the physical form that must be used. If this form is not used, the physical you receive will not be valid for Austin College athletic participation in 2010-2011. Freshmen Only: You may get a copy of the physical you get for school and turn that in for your physical. The additional health forms still need to be filled out and turned in to be eligible. Incoming Freshmen and Transfer Students: Must have written proof of the Meningitis Vaccine 10 days prior to moving onto campus. Those unable to show proof will not be permitted to move onto campus. You will need to provide us with an updated health insurance card. Remember, your insurance must cover intercollegiate athletics. If your current insurance does not cover intercollegiate athletics, Austin College will offer an insurance policy, which you can purchase. This policy will cover intercollegiate athletics for the length of the athletic season only. The supplemental insurance that the health center offers does not cover athletics. Please contact Amanda Parsley ([email protected]) with questions about insurance. Must be done to Play: - Turn in (7 pages total): 1. Medical History (pg 3-4) 2. Physical Form and Pre-existing Conditions Form (pg 5-6) 3. Insurance Information (pg 7) and Copy of Card 4. Austin College Supplement and Drug Form (pg 8) 5. Authorization to Treat (pg 7) 6. Emergency Contact Information (pg 9) - Complete ImPACT Concussion Baseline Testing (instructions attached pg 10) **Freshmen, Transfers & Returning Athletes that sustained a concussion last season** - Read and comply with Athletic Training Room Policies and Procedures (pg 2) ** All forms must be signed and turned in by August 1st. Send forms to: Amanda Parsley Head Athletic Trainer 900 N Grand Ave STE 6A Sherman, TX 75090 Fax 903.813.2514

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AUSTIN COLLEGE ATHLETIC TRAINING ROOM Policies and Procedures The Austin College Athletic Training Room is a professional health care facility, and should be treated as such. By using these facilities, you inherently agree to help maintain an appropriate atmosphere by adhering to the policies outlined below. Those who demonstrate an unwillingness to follow these procedures may be subject to dismissal and any future treatment will be at the discretion of the Head Athletic Trainer. 1. Athletic Training Room HOURS OF OPERATION are as posted based on semester and will be closed during practice times. a. Fall Hours: M-F: 11am-8pm, or until the end of the last practice b. Spring Hours: M-F: 11am-6pm, or until the end of the last practice c. Sat-Sun Treatments: TBA or by appointment only 2. Any kind of rehabilitation or pre-practice concerns need to be done between 11am-3:30pm. a. If any situations arise that prevent a student-athlete from completing these things during this time, other arrangements may be made with the Athletic Training Staff. 3. If a student-athlete requires preventative taping and has class until 4:20pm he/she should get taped prior to going to that class unless otherwise discussed with the Athletic Training Staff and Head Coach. 4. Every student-athlete must sign-in on respective sign-ins prior to treatment and taping. a. Student-athletes will be treated based on order of sign-in. 5. Any student-athlete wishing to get ankles taped for practice must complete ankle rehabilitation a minimum of 3 times per week, no exceptions will be made. a. Any student-athlete wishing to be taped for games must be taped daily for practice and complete rehabilitation requirements. ***Practice how you play*** 6. Treatment of in-season student-athletes takes priority over out-of-season student-athletes. Once a treatment modality has been started it cannot be halted. 7. It is the responsibility of each student-athlete to allow enough time for treatment prior to practice. Ie. Arriving 10 minutes prior to practice is not allowing enough time for pre-practice treatment. 8. Showers are required prior to post-practice treatments. a. All non-traditional season student-athletes are able to shower in swimming locker room. Student-athletes will be responsible for providing own towel and clean clothes. 9. Student-athletes must comply with posted Athletic Training Room Rules. 10. Student-athletes must complete all Pre-Season requirements in order to be eligible. 11. Student-athletes must comply with all NCAA rules and regulations. Including: Banned Substances.

*Please keep as a reference. Do Not return.**

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Austin College Athletics Medical History Sport:_________________________

Name:________________________________________________ Age:______

DOB:______________ Sex:______ Social Security #:__________________________________ Parent/Guardian/Spouse: ______________________________________ Home Phone: _____________ Cell Phone: _________ Permanent Address: ______________________________________________________________________________________ ___________________________________________________________________________________________________ City State Zip Code Local Address: __________________________________________________________________________________________ Address Cell Phone # Email Address

Please answer ALL of the following questions. Any “yes” answers must be initialed by the physician performing your physical examination. Question

Yes

No

Explain any "Yes" answers here. Physician MUST initial.

Have you had a medical illness since your last check-up or athletic physical? When? Have you been hospitalized overnight in the past year? When? Have you had surgery in the past year? When? Are you currently taking any prescription or non-prescription (over the counter) medication or pill, or using an inhaler? Which? Do you have any allergies (pollen, medicine, food, stinging insects, etc.)? Have you ever passed out during exercise? Have you ever been dizzy during or after exercise? Do you get tired more quickly than your friends during exercise? Have you ever had racing of your heart or skipped heartbeats? Have you had high blood pressure or high cholesterol? Have you ever been told you have a heart murmur? Has any family member died of heart problems or had a sudden unexpected death before age 50? Has any family member been diagnosed with enlarged heart, hypertrophic cardiomyopathy, long QT syndrome, Marfan's syndrome, or abnormal rhythm? Have you had a severe viral infection (myocarditis, mononucleosis, etc.) within the past month? Has a physician ever denied or restricted your participation in sports for any heart problems? Do you have any current skin problems (itching, rash, acne, warts, fungus, blisters, etc.)? Have you ever had a head injury or concussion? Have you ever been knocked out, become unconscious or lost your memory? If yes, how many times? How severe was each one? When was the last concussion? Have you ever had a seizure? Do you have frequent or severe headaches?

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Have you ever had numbness or tingling in your arms, hands, legs, or feet? Have you ever had a stinger, burner, or piched nerve? Have you ever become ill from exercising in the heat? Have you ever become unexpectedly short of breath as a result of exercise? Do you cough, wheeze, or have any trouble breathing during or after activity? Do you have asthma? Do you have seasonal allergies requiring treatment? Have you had any problems with your eyes/vision? Are you missing any paired organs? Do you use any special protective or corrective equipment or devices that aren't usually used for your sport/position (joint braces, foot orthotics, retainer, neck roll, hearing aid, etc.)? Have you ever had a sprain or strain? Swelling? Have you ever broken any bones, or dislocated any joints? Which? When? Do you want to weigh more or less than you do now?

Why?

Do you feel streesed out? Do you have a chronic illness or see a physician regularly for any problem? Are you currently under a doctor's care for anything? Do you have sickle cell anemia? Is there a history of sickle cell anemia in your family? Do you have diabetes? Is there a history of diabetes in your family? Do you have any unresolved injuries?

By signing this document, I hereby: A. Certify that all answers I have provided on this document are correct and true. B. Understand that I must refrain from practice or play while ill or injured, whether or not I am receiving medical treatment, until I am discharged from treatment or am given permission by the clinical practitioner to resume participation despite treatment. C. Understand that having passed the physical 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. D. Authorize Austin College Athletic Training to obtain any of my past medical records from hospitals and/or doctor’s offices. A copy of this authorization shall be as valid as the original. E. Understand that by conditioning, practicing, or competing in athletics places me at increased risk of injury. It is further my understanding that it is entirely my responsibility to report any pain or injury to the athletic trainer or physician, and inform them of any current problems. If I do not, or if I fail to comply with their recommendations, Austin College will not be held responsible for those injuries. _______________________________________________________ Athlete Signature

____________________________ Date

_______________________________________________________ Parent/Guardian Signature (if athlete is under 18 years of age)

____________________________ Date

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Austin College Athletics Pre-Participation Physical Examination As per NCAA recommendations, all Austin College student athletes are required to have a pre-participation physical examination by a medical doctor prior to the first day of their respective athletic seasons. This is to be done annually, and must take place within 3 months of the first day of the season. This form must be completed by the examining physician, and is the ONLY paperwork that will be accepted as proof of the required physical examination. The Athletic Training office must have a copy of the completed physical form on file before an athlete will be allowed to participate in ANY training activity (excluding personal workouts) directly related to his/her association with an Austin College athletic team.

Name_______________________________________ Gender_____ Age________ Date of Birth__________________________ Height_________ Weight__________ Heart Rate __________ Blood Pressure _____/_____ (_____/_____ ,_____/_____) NORMAL

ABNORMAL FINDINGS

MEDICAL Appearance Eyes/Ears/Nose Throat Lymph Nodes Heart- Auscultation of the heart in the supine position Heart- Auscultation of the heart in the standing position Heart- Lower extremity pulses Pulses Lungs Abdomen Genitalia (males only) Skin MUSCULOSKELETAL Neck Back Shoulder/Arm Elbow/Forearm Wrist/Hand Hip/Thigh Knee Leg/Ankle Foot

CLEARANCE Cleared (No Restrictions) Not cleared for: _________________________________ Reason:_______________________________________________ Recommendations:____________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Name of Examining Physician (print/type)_____________________________________ Date of Examination _________________ Address: ___________________________________________________________________________________________________ Phone number: _______________________________

Signature_________________________________________________ 5

Austin College Athletics Pre-Existing/Previous Orthopedic Conditions Name_____________________________________________

Sport______________________

Please give a brief history (including dates) of any pre-existing or previous significant orthopedic conditions. (Examples: Right ACL tear 3/03, Left AC sprain 11/01, etc.) Also, please circle/date the injured body part on the figure below. History: Physician__________________________________________

I acknowledge that I have had or currently have the above noted previous and/or pre-existing condition(s), and I will not hold Austin College responsible for any debts incurred by me for any conditions not resulting from direct participation in Austin College Athletics. _______________________________________________________ Signature of Student (or Guardian if student under 18 years of age)

____________________________ Date 6

Austin College Athletics Assumption of Risk The responsibility for sport safety must be shared by administrators, coaches, physicians, athletic trainers, and student-athletes. I, the undersigned, am aware and appreciate that there are risks of injury involved in my participation in intercollegiate athletics at Austin College. I, and the school understand that my signature below in no way relieves the school of its responsibilities for my welfare. Signing this statement is intended to make me aware of my responsibilities in preventing potential injuries or harm, reporting actual injuries, and complying with the treatment plan of my health care providers and indicates that I understand and appreciate the risks involved with my participation. I understand that this includes the risk of brain and spinal cord injury that may result in paralysis, other permanent injury, or possibly death. Female athletes with menstrual irregularities may experience a devastating effect on bone density that results in osteoporosis (decrease in bone density). I understand and appreciate the increased risk of stress fractures due to the loss of bone density that results from menstrual irregularities and know that I should seek prompt medical attention if this condition develops or exists, ensuring appropriate preventive measures. I acknowledge that the above statements of Assumption of Risk were read and that I understand them. _______________________________________________________ Signature of Student (or Guardian if student under 18 years of age)

____________________________ Date

Insurance Information 1. Policy Holder’s Name_________________________________________ SS#___________________________ 2.

Insurance Co. and Claims Address____________________________________________________________________ ____________________________________________________________________ (Found on the Back of the Insurance Card)

3.

Insurance Phone #_________________________________________ (Found on the Back of the Card)

4.

Group #___________________

5.

Please indicate if medical insurance above covers intercollegiate athletics: _____YES _____NO *insurance must cover intercollegiate athletics to participate

Plan ID #__________________

Insurance Co. Phone __________________

Authorization I authorize AC athletic trainers, and any medical doctor, physician’s assistant, and/or registered nurse who may treat me, to disclose any health care information related to injuries/illnesses I may receive this year (including medical history, diagnosis, treatment, or prognosis) to the following Austin College personnel: Vice President for Student Affairs Director of Health Services Director of Counseling Service Director of Student Life Professional Residence Hall Staff

Athletics only (initial)_______ Director of Athletics Team Coach Certified Athletic Trainer

_____________________________________________________ Signature of Student (or Guardian if student under 18 years of age)

________________ Date 7

Austin College Athletics Student-Athlete Drug/Nutritional Supplement Disclosure Statement I, (printed name)_____________________________________, acknowledge and understand that many compounds obtained from nutritional stores are not subject to the strict regulations of the United States Food and Drug Administration, and therefore the contents of such substances may not be represented accurately and may contain impurities or banned substances, which may cause me to test positive. I understand that labeling on these products may be misleading and/or inaccurate, and that sales personnel are paid only to sell the product, and cannot accurately certify that these products contain no substances banned by the NCAA. Terms such as “healthy” or “naturally occurring” do not necessarily mean they are safe to take or use, or that the NCAA endorses a product or approves its usage. I also understand that some substances may interact negatively with prescribed medications. I acknowledge that BEFORE taking or using any drug or supplement, I have sole responsibility for taking appropriate steps to ensure that it does not contain any substance banned by the NCAA. I also acknowledge the risk of losing my eligibility to participate in intercollegiate athletics if I test positive for an NCAA banned substance, REGARDLESS of the source of the substance or reason for its presence. The following list is a full disclosure of all drugs and/or supplements I have taken in the last 60 days, am currently taking, or intend to take in the coming months. By making this disclosure, I am requesting that these products and their ingredients be reviewed by the Austin College Athletic Training staff for the purposes of determining whether they are medically safe to use and do not contain substances banned by the NCAA. I understand that I should not take or use these products unless their use has been approved by the Head Athletic Trainer. (Please list the following for each item: name, dosage, amount taken, ingredients, when taken, and what it was taken for. Use the back of this form if necessary.) 1. Prescription Drugs (anything prescribed by your doctor)

2. Over the counter medications (anything you can buy yourself at the store, such as Tylenol, Robitussin, Advil, etc.)

3. Vitamins, minerals, herbs, or extracts

4. Other nutritional ergogenic aids (energy bars/drinks, protein powders/drinks, creatine, etc.)

I hereby certify that I have read and understand this document, and that the answers provided are true and accurate. _______________________________________________________ Signature of Student (or Guardian if student under 18 years of age)

____________________________ Date

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Emergency Contact Information Name:

Sport:

Emergency Contact/Relationship:

Emergency Contact Phone Numbers: -Cell: -Home: -Work: Medications:

Allergic to:

Please Return by August 1st to: Amanda Parsley 900 N Grand Ave STE 6A Sherman, TX 75090 [email protected]

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Austin College - ImPACT Test Instructions **ALL FRESHMEN, TRANSFER STUDENTS and RETURNING ATHETES THAT SUSTAINED A CONCUSSION LAST SEASON Please Note: This test provides the Austin College Athletic Training Staff with a baseline measure and is used as a tool in concussion assessment. Taking this test seriously will ensure adequate concussion assessment and healthy return to activity.

• Test must be taken with a MOUSE, preferably on a desktop. • Environment must be FREE FROM DISTRACTIONS (No TV, No CELL PHONES). • You cannot pass or fail this test – its an individualized measurement. • Testing time is about 45 minutes. 1) Go to the link: www.impacttestonline.com/presbyteriansportsnetwork 2) Click on “Launch Baseline Test” 3) Click on “English” or “Spanish” (choose the language that is most comfortable for you) 4) Read the instructions: “Before you begin…” then click “next”. 5) Read: “The ImPACT testing process is made up of three components…” then click “next” 6) Click the circle next to “unsupervised” 7) In the “School/Organization” box click on the down arrow and select “Austin College” 8) Fill in your date of birth 9) Continue filling in your information and begin the exam. 10) DIRECTIONS ARE LISTED AT THE BEGINNING OF EACH MODULE – READ CAREFULLY. INSTRUCTIONS ARE NOT TIMED, BUT MOST MODULES ARE.

For questions or more information, please contact: Amanda Parsley, M.S., ATC, LAT (903)813-2514

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