Stephen F. Austin State University Old / Returning Athlete

2013-'14 Academic Year

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Stephen F. Austin State University Athlete Demographics Last Name:

First Name:

Middle Name:

Nickname:

SS#: ______ - ____ - ________

Campus ID # _______ - ________

Birth Date: ____ / ____ / ________

Age: ____

Sex:

M / F

Preferred Email Address:

Sport: Marital Status: S / M / D

@

Current SFA Classification: Sophomore

Incoming Freshman

Red Shirt Freshman

Junior

Senior

Which of the following, best describes your current team status: Partial Scholarship

Recruited Walk-on

Full Scholarship Walk-on

Dorm / Apt. Phone:

(______) _____ - _______

Mobile Phone:

(______) ______ - ______

Home Phone:

(______) _____ - _______

Mobile Phone:

(______) _____ - _______

Work Phone:

(______) _____ - _______

Home Phone:

(______) _____ - _______

Mobile Phone:

(______) _____ - _______

Work Phone:

(______) _____ - _______

Contact Person in Case of an Emergency (Non-Relative):

Home Phone:

(______) _____ - _______

Name:

Mobile Phone:

(______) _____ - _______

Phone:

(______) _____ - _______

Local / Campus / Dorm / Apt. Address: City:

State:

Zip:

Father / Guardian: Home Address: City:

State:

Zip:

Email Address: Mother / Guardian: Home Address: City:

State:

Zip:

Email Address:

Relationship:

Family Physician:

2013-'14 Academic Year

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SFASU Insurance Information Questionnaire Athlete’s Name

Sport

Social Security Number (Athlete) Parent / Guardian Information Father/Guardian Name

Mother/Guardian Name

Address

Address

Telephone

Telephone

Email Address:

Email Address: Is Father employed?

Yes / No

Employer

Employer

Emp. Address

Emp. Address

Emp. Telephone

Emp. Telephone Is Father insured?

Yes / No

If “No”, please sign here:

Is Mother employed?

Yes / No

Is Mother insured?

Yes / No

If “No”, please sign here:

Is student athlete covered under this plan? Yes / No

Is student athlete covered under this plan? Yes / No

Is this an HMO policy?

Is this an HMO policy?

Yes / No

Yes / No

Does the HMO network provide coverage in the

Does the HMO network provide coverage in the

Nacogdoches area?

Nacogdoches area?

Yes / No

Yes / No

Does the athlete have a primary care physician that

Does the athlete have a primary care physician that

is NOT located in the Nacogdoches area? Yes / No

is NOT located in the Nacogdoches area? Yes / No

Insurance Company Plan

Insurance Company Plan

Policy Number

Policy Number

Group Number

Group Number

I authorize the release of any medical information necessary to process this claim. I also request payment of government benefits, either to myself, or to the party who accepts assignments below. I authorize payment of medical benefits to physicians or suppliers of medical services.

I authorize the release of any medical information necessary to process this claim. I also request payment of government benefits, either to myself, or to the party who accepts assignments below. I authorize payment of medical benefits to physicians or suppliers of medical services.

Signature of Insured (Parent)

Signature of Insured (Parent)

Date

Date

Social Security Number of Insured (Parent)

Social Security Number of Insured (Parent)

Birth Date of Insured (Parent)

Birth Date of Insured (Parent)

My insurance company requires special forms to be filled out: If yes, please attach signed forms.

Yes / No

My insurance company requires special forms to be filled out: Yes / No If yes, please attach signed forms.

* Please bring your insurance card to the Athletic Training Room for scanning, * and attach a copy of the front and back of your insurance card(s) here.

2013-'14 Academic Year

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2013-'14 Academic Year

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Form 13-3d

Academic Year 2013-14

Drug-Testing Consent − NCAA Division I

For: Action: Due date:

Required by: Purpose: Effective date:

Student-athletes. Sign and return to your director of athletics. At the time your intercollegiate squad first reports for practice or the Monday of the institution's fourth week of classes, whichever date occurs first. NCAA Constitution 3.2.4.7 and NCAA Bylaw 14.1.4. To assist in certifying eligibility. This consent form shall be in effect from the date this document is signed and shall remain in effect until a subsequent Drug-Testing Consent Form is executed.

Requirement to Sign Drug-Testing Consent Form. Stephen F. Austin State University Name of your institution: _____________________________________________________________

Name of student-athlete: ________________________________________ Sport(s): ________________ You must sign this form to participate (i.e., practice or compete) in intercollegiate athletics per NCAA Constitution 3.2.4.7 and NCAA Bylaw 14.1.4. If you have any questions, you should discuss them with your director of athletics. Consent to Testing. You agree to allow the NCAA to test you in relation to any participation by you in any NCAA championship or in any postseason football game certified by the NCAA for the banned drugs listed in Bylaw 31.2.3 (attached). Examples of drugs under each class can be found at www.ncaa.org/drugtesting. Note: There is no complete list of banned substances. Check the Resource Exchange Center for questions about supplements, medications and banned drugs. Additionally, if you participate in a NCAA Division I sport, you also agree to be tested on a year-round basis. Consequences for a Positive Drug Test. By signing this form, you affirm that you are aware of the NCAA drug-testing program, which provides: 1.

A student-athlete who tests positive shall be withheld from competition in all sports for a minimum of 365 days from the drug-test collection date and shall lose a year of eligibility;

2.

A student-athlete who tests positive has an opportunity to appeal the positive drug test;

3.

A student-athlete who tests positive a second time for the use of any drug other than a "street drug" shall lose all remaining regular-season and postseason eligibility in all sports. A combination of two positive tests involving street drugs (marijuana, THC or heroin), in whatever order, will result in the loss of an additional year of eligibility;

4.

The penalty for missing a scheduled drug test is the same as the penalty for testing positive for the use of a banned drug other than a street drug; and

Drug-Testing Consent – NCAA Division I Form 13-3d Page No. 2 _________

5.

If a student-athlete immediately transfers to a non-NCAA institution while ineligible because of a positive NCAA drug test, and competes in collegiate competition within the 365-day period at a non-NCAA institution, the student-athlete will be ineligible for all NCAA regular-season and postseason competition until the student-athlete does not compete in collegiate competition for a 365-day period.

Signatures. By signing below, I consent: 1.

To be tested by the NCAA in accordance with NCAA drug-testing policy, which provides among other things that: a.

I will be notified of selection to be tested;

b.

I must appear for NCAA testing or be sanctioned for a positive drug test; and

c.

My urine sample collection will be observed by a person of my same gender.

2.

To accept the consequences of a positive drug test;

3.

To allow my drug-test sample to be used by the NCAA drug-testing laboratories for research purposes to improve drug-testing detection; and

4.

To allow disclosure of my drug-testing results only for purposes related to eligibility for participation in NCAA competition.

I understand that if I sign this statement falsely or erroneously, I violate NCAA legislation on ethical conduct and will jeopardize my eligibility. _______________________ Date

____________________________________________________ Signature of student-athlete

_______________________ Date

____________________________________________________ Signature of parent (if student-athlete is a minor)

_________________________________________ Name (please print)

__________________ Date of birth

_________ Age

____________________________________________________________________________________ Home address (street, city, state and zip code) ___________________________________________________________________________________ Sport(s) What to do with this form: Sign and return it to your director of athletics at the time your intercollegiate squad first reports for practice or the Monday of the institution's fourth week of classes (whichever date occurs first). This form is to be kept on file at the institution for six years.

ATTACHMENT 2013-14 NCAA Banned Drugs

It is your responsibility to check with the appropriate or designated athletics staff before using any substance The NCAA bans the following classes of drugs: a. b. c. d. e. f. g. h.

Stimulants Anabolic Agents Alcohol and Beta Blockers (banned for rifle only) Diuretics and Other Masking Agents Street Drugs Peptide Hormones and Analogues Anti-estrogens Beta-2 Agonists Note: Any substance chemically related to these classes is also banned. The institution and the student-athlete shall be held accountable for all drugs within the banned drug class regardless of whether they have been specifically identified. Drugs and Procedures Subject to Restrictions: a. b. c. d. e.

Blood Doping. Local Anesthetics (under some conditions). Manipulation of Urine Samples. Beta-2 Agonists permitted only by prescription and inhalation. Caffeine if concentrations in urine exceed 15 micrograms/ml.

NCAA Nutritional/Dietary Supplements Warning: Before consuming any nutritional/dietary supplement product, review the product with the appropriate or designated athletics department staff! • • • •

Dietary supplements are not well regulated and may cause a positive drug test result. Student-athletes have tested positive and lost their eligibility using dietary supplements. Many dietary supplements are contaminated with banned drugs not listed on the label. Any product containing a dietary supplement ingredient is taken at your own risk.

2013-14 NCAA Banned Drugs Page No. 2 _________

Note to Student-Athletes: There is no complete list of banned substances. Do not rely on this list to rule out any supplement ingredient. Check with your athletics department staff prior to using a supplement. Some Examples of NCAA Banned Substances in Each Drug Class Stimulants: amphetamine (Adderall); caffeine (guarana); cocaine; ephedrine; fenfluramine (Fen); methamphetamine; methylphenidate (Ritalin); phentermine (Phen); synephrine (bitter orange); methylhexaneamine, “bath salts” (mephedrone) etc. exceptions: phenylephrine and pseudoephedrine are not banned. Anabolic Agents (sometimes listed as a chemical formula, such as 3,6,17-androstenetrione): Androstenedione; boldenone; clenbuterol; DHEA (7-Keto); epi-trenbolone; etiocholanolone; methasterone; methandienone; nandrolone; norandrostenedione; stanozolol; stenbolone; testosterone; trenbolone; etc. Alcohol and Beta Blockers (banned for rifle only): alcohol; atenolol; metoprolol; nadolol; pindolol; propranolol; timolol; etc. Diuretics (water pills) and Other Masking Agents: bumetanide; chlorothiazide; furosemide; hydrochlorothiazide; probenecid; spironolactone (canrenone); triameterene; trichlormethiazide; etc. Street Drugs: heroin; marijuana; tetrahydrocannabinol (THC); synthetic cannabinoids (e.g., spice, K2, JWH-018, JWH-073) Peptide Hormones and Analogues: growth hormone(hGH); human chorionic gonadotropin (hCG); erythropoietin (EPO); etc. Anti-Estrogens : anastrozole; tamoxifen; formestane; 3,17-dioxo-etiochol-1,4,6-triene(ATD), etc. Beta-2 Agonists: bambuterol; formoterol; salbutamol; salmeterol; etc. Additional examples of banned drugs can be found at www.ncaa.org/drugtesting. Any substance that is chemically related to the class, even if it is not listed as an example, is also banned! Information about ingredients in medications and nutritional/dietary supplements can be obtained by contacting the Resource Exchange Center, REC, 877-202-0769 or www.drugfreesport.com/rec password ncaa1, ncaa2 or ncaa3. It is your responsibility to check with the appropriate or designated athletics staff before using any substance. http://documentcenter.ncaa.org/msaa/ama/Compliance/ComplianceForms/2013-14/DivisionI/DIForm13-3dDrug-TestingConsent_061213_JHW/MW:dks

Student-Athlete Authorization/Consent for Disclosure of Protected Health Information for NCAA-Related Research Purposes Stephen F. Austin State University I, ____________________________ hereby authorize ___________________________________ Name of Student-Athlete Name of my Institution

and its physicians, athletic trainers and health care personnel to disclose my protected health information including, without limitation, any information regarding any injury, illness, treatment or participation related to or affecting my training for and participation in intercollegiate athletics to the National Collegiate Athletic Association (NCAA), and its designated employees, agents and/or contractors. I further authorize the NCAA to disclose, and/or use, such information as provided herein. I understand that my participation and protected health information may be disclosed to, and/or used by, the NCAA, and authorized third parties to receive such information for the purpose of using injury, relevant illness and participation information collected from multiple student-athletes and institutions in a manner that does not identify myself or my school. The information is provided to NCAA committees, athletics conferences and individual schools, and NCAA-approved researchers to evaluate the effectiveness of health and safety rules and policy, and to study other sports medicine questions. Selected de-identified summary (aggregate) data also are made accessible to the general public as a service to further the general understanding of athletic injury patterns and help develop education on student-athlete health topics. I am making this authorization/consent voluntarily to release my health information otherwise protected by federal regulations under either the Health Information Portability and Accountability Act (HIPAA) or the Family Educational Rights and Privacy Act of 1974 (the Buckley Amendment). The NCAA and institution are not requiring this authorization/consent to be signed. I understand that while HIPAA regulations may not apply to NCAA use or disclosure of my injury/illness information, the NCAA is committed to protecting my privacy. I understand that my data will be stored securely within industry standards. This authorization/consent for transfer of protected health information expires 545 days from the date of my signature below, but I have the right to revoke it in writing at any time by sending written notification to the director of athletics at my institution. I understand that a revocation takes effect on its request date and does not affect any action taken prior to that date.

Printed Name of Student-Athlete

_____________________________________ Signature Date

http://documentcenter.ncaa.org/msaa/ama/Compliance/ComplianceForms/2013-14/DivisionI/HIPAABuckley2013_050313_JW:dks

Stephen F. Austin State University Department of Athletics DRUG TESTING CONSENT FORM

I have received a copy of the "Stephen F. Austin State University Department of Athletics Drug Testing Program" included in the SFASU StudentAthlete Handbook. I have read it, been given the chance to ask questions about it, and fully understand its provisions. I desire and agree to participate in the Program and to be subject to its terms. I accept the team physician or physicians employed by the University as my personal physicians for the limited purposed of overseeing my participation in the Program, the obtaining of urine specimens from me by the Program Administrators from time to time, the testing and analysis of such specimens (including testing and analysis for possible presence in my system of any amphetamines, steroids, marijuana-related substances, cocaine, or other drugs or controlled substances), the keeping of confidential records and results of such tests, and related activities as set forth in the Program. I agree to cooperate in furnishing my urine specimens from time to time as required. I further agree and consent to the disclosure of the records and test results relating to myself only to those persons and only under the circumstances described in the Program. This consent includes the possible release of the records and test results relating to myself, to my parents (or guardians) or spouse. Further, this consent is given pursuant to all state and federal laws governing privacy, public records, and education records, and is a waiver of my rights to non-disclosure of my records and test results only to the extent of the disclosures authorized in the Program. DATE: SIGNATURE

SOCIAL SECURITY NUMBER

PRINTED NAME

Signature may be that of an athlete over 18 years of age; if under 18, please have it signed by parent or guardian.

PARENT OR GUARDIAN

2013-'14 Academic Year

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STEPHEN F. AUSTIN STATE UNIVERSITY ATHLETIC TRAINING DEPARTMENT Mild Traumatic Brain Injury (MTBI) / Concussion Fact Sheet Definition of Concussion: A concussion is a brain injury that is caused by a traumatic force to the head or another part of the body. This injury can occur in any sport and presents itself uniquely in each individual. A concussion can be mild or severe and can occur even if a person does NOT lose consciousness. Signs/Symptoms of MTBI / Concussion Loss of consciousness (LOC) Visual disturbances (blurry, double vision) Headache Photophobia (sensitivity to light) Confusion Phonophobia (sensitivity to loud noises) Amnesia (PTA) (Memory Loss) Disequilibrium Feeling “in a fog” or “zoned out” Emotional Changes Disorientation Vacant stare Inability to focus Delayed verbal and motor responses Dizziness Slurred/ incoherent speech Nausea/Vomiting Irritability Excessive drowsiness **If you recognize any of these signs/symptoms in yourself or a fellow athlete be sure to report it to your athletic trainer or coach immediately.** If an athlete has sustained a concussion, be aware of the warning signs/symptoms of post-concussion syndrome as listed below and call 911 if symptoms progress rapidly. Symptoms of Post-Concussion Syndrome Loss of intellectual capacity Lack of concentration Sleep disturbances Poor recent memory Poor attention Depressed mood Personality changes Fatigue/irritability Anxiety Headaches Phono/photophobia Twitching/seizures Dizziness Nausea/vomiting Balance issues Fluid/blood coming from nose/ears Loss of consciousness Weak/numb extremities Preventing Concussions: Athletes—  Practice good sportsmanship and skills of your specific sport.  Do not lead with your head/helmet or strike another person in the head/helmet.  Follow rules/regulations accordingly for your sport. Coaches—  Educate student-athletes about concussion signs/symptoms.  Acknowledge that safety comes first.  Prevent long term issues by recognizing those with head injuries and seeking medical attention immediately. You can help to protect yourself from a MTBI/concussion by understanding the signs/symptoms, practicing safety and good sportsmanship during competition, and following the rules of your sport. While a concussion may still occur with activity, it is important to know that you should not hide a suspected concussion and instead should be thoroughly evaluated by an athletic trainer or physician to prevent long term damage. 2013-'14 Academic Year

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STEPHEN F. AUSTIN STATE UNIVERSITY ATHLETIC TRAINING DEPARTMENT Responsibility to Report Injuries and Illnesses Statement Concussion Addendum

I,

, acknowledge and affirm that I have been

educated on mild traumatic brain injury (MTBI) / concussions and the importance of notifying an Athletic Trainer and/or member of the Sports Medicine staff as soon as I am aware that I may have developed signs and/or symptoms of a concussion. I understand and affirmatively accept full responsibility for my safety and health while participating in intercollegiate athletics at Stephen F. Austin State University, including reporting any injury or illness to Athletic Training staff, and am duly aware of the dangers in continued participation with any such injury or illness and that I will not allow my desire to play impede my judgment or cause me to give false information to the evaluating Athletic Trainer.

I also HEREBY give my permission for the Athletic Trainer and/or physician to make all return to play decisions on my concussion status. I also understand that I will fully cooperate with the Athletic Training staff and physicians in the management of my concussion(s).

This agreement will remain in effect for the duration of my intercollegiate career at Stephen F. Austin State University

Student-Athlete Signature:

Date:

Athletic Trainer Signature:

Date:

2013-'14 Academic Year

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2013-'14 Academic Year

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(Returning Athletes)

STEPHEN F. AUSTIN STATE UNIVERSITY ANNUAL HEALTH QUESTIONNAIRE & RE-EXAMINATION Shared Responsibility for Sport Safety Participation in sport requires an acceptance of risk of injury. Athletes rightfully assume that those who are responsible for the conduct of sport have taken reasonable precautions to minimize such risk and that their peers participating in the sport will not intentionally inflict injury upon them. Periodic analysis in injury patterns lead to refinements in the rules and other safety decisions. However, to legislate safety via a rule book and to rely on officials to enforce compliance with the rule book is an insufficient as to rely on warning labels to produce compliance with safety guidelines. "Compliance" means respect on everyone's part for the intent and purpose of a rule or guideline. This annual form must be completed and returned before the student-athlete will be permitted to practice or play. The National Collegiate Athletic Association's policies recommend that all student-athletes have a qualifying intercollegiate athletic physical and an annual "health-state" review. Stephen F. Austin State University supports this NCAA policy. Further medical evaluations may be required for specific matters. Date of initial medical evaluation: ____ / ____ / ________

Date of the most recent medical update: ____ / ____ / ________

CIRCLE YES

NO

1.

YES YES

NO NO

2. 3.

YES YES YES YES

NO NO NO NO

4. 5. 6. 7.

YES

NO

8.

YES YES

NO NO

9. 10.

YES

NO

11.

Have you been hospitalized or had a major illness since your last Health History Reexamination at SFASU? Are you currently ill or injured in any way? Have you had a major injury (including cerebral concussion) since your last Health History Reexamination at SFASU? Do you currently have any incompletely healed injury? Are you taking any medication on a regular or continuing basis? Are you currently taking any short-course medication for a specific current illness, injury, etc.? Have you had any operations or surgery since your last Health History Re-examination at SFASU? Have you had any accidents and/or fractures since you last Health History Re-examination at SFASU? Have you seen a physician for any reason in the last year? Do you know of, or do you believe there is, any health reason why you should not participate in Stephen F. Austin State University's intercollegiate athletic programs at this time? Would you like to discuss your current health with the team physician?

Please explain if you answered yes to any of the above questions.

The undersigned, herewith: A. Understands that he or she must refrain from practice while ill or injured, whether or not receiving medical treatment until he or she is discharged from treatment or is given permission by the clinical practitioner to restart participation despite continuing treatment. B. Understands that having passed the physical examination does not necessarily mean that he or she is physically qualified to engage in athletics, but only that the evaluation did not find a medical reason to disqualify him or her at the time of said examination. C. Certifies that the answers to the questions above are correct and true. SIGNATURE:

DATE:

2013-'14 Academic Year

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TO BE COMPLETED BY STEPHEN F. AUSTIN STATE UNIVERSITY MEDICAL STAFF

Comments:

Athlete needs to be referred to:

Orthopaedic

General Medicine

Medical Specialist

Referred to:

A.T.C., L.A.T.

ATHLETIC TRAINER SIGNATURE:

DATE:

EXAMINATION:

[

] CLEARED

[

] PRIOR TO PARTICIPATING,

ATHLETE REQUIRES

[

] NOT CLEARED

DATE: ____ / ____ / _______

PHYSICIAN SIGNATURE:

Height:

Weight:

Blood Pressure:

2013-'14 Academic Year

Pulse:

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