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North Park UniversityIntercollegiate Athletics Pre-Participation PacketFor Incoming Student-AthletesPrior to participating in any practice or competition within North Park University Intercollegiate Athletics, the followingPre-Participation Packet needs to be completed and reviewed by the Athletic Training Staff. Please use the followingchart as a checklist to gather all forms prior to your sport’s organized activities for the academic year. Please check the box to the left when the item has been read/completed!Page 2: Informed Consent for Medical Treatment & Assumption of Risk/SharedResponsibility: Read, sign and date. (Parent/guardian if under 18).Page 3-4: Student-Athlete Authorization and Consent for Disclosure of HealthInformation to North Park University: Read, sign, and date. This allows the medical staff tocommunicate your condition with each other in addition to relevant NPU personnel (coaches,physicians, specialists, etc.) (Parent/guardian if under 18).Page 5: North Park University Health Insurance Information: No signature necessary.Important to read about the necessity for health insurance before participating in athletics aswell as the North Park University Athletics’ excess policy.Page 6: Personal/Emergency Contact Information & Disclosure of Health Information toFirst Agency, Inc.: Fill out completely, including whom to contact in an emergency. Read,Print, Sign, Date. (Parent/guardian if under 18).Page 7: ADHD Medication Reporting Form: Many medications used to treat ADHD arerestricted substances by the NCAA. If this is applicable to you, complete the form & attachdocumentation from your treating physician. If this does not apply to you, leave this form blank.Page 8: North Park University Athletics Drug Testing Consent Form: North Park has aninstitutional policy for all student-athletes at North Park University separate from the NCAA. Byreading, signing and dating (parent/guardian if under 18) you agree to the policy, which can befound in full in the Student Athlete Handbook at athletics.northpark.edu.Page 9-10: Sickle Cell Education and Testing Compliance Form: Only for student-athletesnew to North Park Intercollegiate Athletics. Read, sign, date and include proof of testing/resultsif applicable (parent/guardian if under 18).Page 11: CCIW Injury and Illness Reporting Acknowledgement Form: Only for studentathletes new to North Park Intercollegiate Athletics. Read, sign, and date.Page 12: Health History Form: Read all sections carefully and complete all requestedinformation. Elaborate upon any “YES” answers in the space provided. After finishing, sign anddate at the bottom (parent/guardian if under 18).Page 13: Physical Examination Form: According to the NCAA guidelines, the Physical FormMUST BE SIGNED BY AN MD or DO. Physicals signed by a Nurse Practitioner (NP),Physician’s Assistant (PA-C), etc. will NOT be accepted.YOU MUST INCLUDE A COPY OF THE FRONT AND BACK OF ALLCURRENT INSURANCE CARDS. See more information on page 5.Please read the following statements carefully and then print, sign and date (parent/guardian if under 18). Bysigning, the student-athlete indicates that he/she understands and accepts these policies and that the studentathlete will not be permitted to participate in any organized activity until he/she has signed this form. I understand that my passing a physical examination by a physician does not necessarily meanthat I am physically qualified to engage in intercollegiate athletics, but only that the M.D or D.O. didnot find a medical reason to disqualify me.I understand that, if the physical examination portion of this form is filled out by anyone other than aphysician, or if I knowingly include any false information on any part of this form, I will be immediatelyexcluded from participation in intercollegiate athletics at North Park for one calendar year.Printed Name: Signature: Date: / /Sport(s) Parent/Guardian (if under 18)1
North Park University Intercollegiate AthleticsAthletic Training ServicesInformed Consent for Medical Treatment FormI hereby grant my permission to the North Park University team physicians, athletic training staff, and athletictraining students to assess, treat, and rehabilitate any injury that I may suffer as a result of my participation in theNorth Park University intercollegiate athletic program. I understand that any treatment, medical or surgical carethat is provided to me will be done only if it is considered medically necessary for my health.I hereby grant my permission to the North Park University team physicians and athletic training staff to refer meas they deem appropriate to the appropriate medical personnel, to a hospital, or any other medical facility fortreatment for any injury or illness that I may suffer as a result of my participation in the North Park Universityintercollegiate athletic program.Student-Athlete’s Signature: Date: / /Parent/Guardian’s Signature:Date: / /(If Student-Athlete is under 18 years of age)North Park University Intercollegiate AthleticsAthletic Training ServicesAssumption of Risk and Shared Responsibility FormParticipation in intercollegiate athletics involves the inherent risk of injury, the severity of which may rangefrom minor to catastrophic, or from temporary impairment to permanent disability, including paralysis or death.Since the participation in sports requires an acceptance of the risk of injury by the student-athlete, he or sherightfully assumes that reasonable precaution will be taken to minimize the risk of serious injury. Student-athleteshave this informed awareness of the risks and share the responsibility for minimizing those risks.Student-athletes must comply with all safety guidelines, inspect their equipment daily, and follow athletic trainingroom rules and procedures; report all physical problems to the athletic training staff and adhere to establishedinjury management guidelines, which include total rehabilitation and reassessments before being released to fullparticipation.Having read the above statement I am aware of the inherent risk of injury involved in athletic participation. Finally, Iunderstand that in accepting the risks associated with athletic participation I will also share the responsibility ofminimizing those risks.Student-Athlete’s Signature: Date: / /Parent/Guardian’s Signature:Date: / /(If Student-Athlete is under 18 years of age)2
STUDENT-ATHLETE AUTHORIZATION AND CONSENTFOR DISCLOSURE OF HEALTH INFORMATIONTO NORTH PARK UNIVERSITYTO STUDENT-ATHLETE:1.HIPAA Protection and Potential Loss of HIPAA Protection. You understand that informationrelated to your health is protected by federal regulations under the Health Insurance Portability andAccountability Act (HIPAA) and that, under certain circumstances, North Park University may beprecluded from disclosing such information without your authorization under HIPAA. You furtherunderstand that there is the potential that information disclosed pursuant to this authorization and consentmight be re-disclosed by the recipient under circumstances such that the information will no longerprotected by HIPAA.2.Your Authorization to Use and Disclose Certain Health Care Information. By signing this form,you authorize and consent to the use and disclosure of any information, other than psychotherapycounseling notes, whether oral or recorded in any form or medium, relating to: (i) your past, present, orfuture physical or mental health or condition; or, (ii) any services or supplies related to your past, present,or future physical or mental health or condition, including without limitation (a) any preventive, diagnostic,therapeutic, rehabilitative, maintenance, or palliative care, (b) any counseling, service, assessment orprocedure with respect to your physical or mental condition or functional status affecting you or thestructure or function of your body, (c) any sale or dispensing of a drug, device or equipment to you inaccordance with a prescription or otherwise, or (d) any past, present or future financial rights orobligations of any person, entity, organization or governmental body with regard to the forgoing servicesand supplies. For purposes of this authorization and consent the information described in the precedingsentence is referred to as “Your Health Care Information”.3.Persons and Groups You Authorize to Use and Disclose Your Health Care Information andPurposes for Which You Authorize Your Health Care Information to be Disclosed. You authorize NorthPark University and its employed or otherwise affiliated physicians, athletic trainers, student athletictrainers, coaches, health care, and administrative personnel to use, and subject to the followingparagraph, disclose Your Health Care Information for any purpose: (i) related to the rendering or deliveryof any services or supplies, directly or indirectly, by any person, entity, organization or governmental bodyin furtherance of any preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care,or any counseling, service, assessment or procedure with respect to your physical or mental condition orfunctional status affecting you or the structure or function of your body; (ii) related to any past present orfuture financial rights or obligations of any person, entity, organization or governmental body with regardto the foregoing services and supplies; or (iii) related to your eligibility to participate in athletic activitiesor programs organized, sponsored, or otherwise supported by North Park University.4.Persons to Whom You Authorize Your Health Care Information to be Disclosed. In furtherance ofthe purposes described in the preceding paragraph, you authorize North Park University and its employedor otherwise affiliated physicians, athletic trainers, coaches, health care, and administrative personnel todisclose Your Health Care Information to each other and to any person, entity, organization orgovernmental body that: (i) renders or delivers, or which has or is expected to render or deliver, directlyor indirectly, any services or supplies in furtherance of any preventive, diagnostic, therapeutic,rehabilitative, maintenance, or palliative care, or any counseling, service, assessment or procedure withrespect to your physical or mental condition or functional status affecting you or the structure or functionof your body, (ii) has, has had, or may have, any financial rights or obligations with respect to the foregoingservices and supplies, or (iii) provides oversight or requires reporting with respect to athletic activities orprograms organized, sponsored, or otherwise supported by North Park University.3
STUDENT-ATHLETE AUTHORIZATION AND CONSENTFOR DISCLOSURE OF HEALTH INFORMATIONTO NORTH PARK UNIVERSITY5.Your Right to Revoke This Authorization and Exceptions to That Right. You understand that,subject to the exceptions contained in this paragraph, you may revoke this authorization and consent atany time by delivering a written revocation to North Park University’s Athletic Director. You understandthat no revocation by you will be effective to the extent that North Park University has taken action, orallowed action to be taken on its behalf, in reliance on this authorization and consent. You furtherunderstand that, if this authorization was obtained as a condition of obtaining insurance coverage, otherlaw provides the insurer with the right to contest a claim under the policy or the policy itself.6.Authorization Not a Condition of Treatment. You understand that this authorization and consentis voluntary and not required by North Park University for medical treatment, payment for treatment,enrollment in a health plan or for any benefits that North Park University may, in its sole discretion, offeror extend to you.7.Expiration. This authorization and consent expires three hundred eighty (380) days after the lastdate that you participate in any athletic activity or program sponsored by North Park University.8.Acknowledgement. By signing this authorization and consent you acknowledge that you haveread, understand, and agree to the foregoing provisions and that you have received a signed copy of thisauthorization and consent.Name of student-athlete (print)DateSignature of student-athleteIf applicable (under 18):Name of legal representativeDateSignature of legal representativePlease describe the nature of your authority to act on behalf of the aboveStudent-Athlete (e.g. parent, legal-guardian):4
North Park University Intercollegiate Student-Athlete Insurance Policy & InformationWhile participating in college athletics injuries can and do occur. At North Park University we strive to give our studentathletes the best care possible. Although much of your healthcare can be provided for via NPU athletic training services,team physicians and on-campus Health Services and Counseling Center, some medical bills are inevitable (x-ray, labfees, prescriptions, specialist appointments, surgeries, etc.). Because of this, it is important that we review health andmedical insurance coverage.As an intercollegiate student-athlete you are covered by an athletic accident insurance plan provided by North ParkUniversity. This policy provides coverage if you sustain a moderate to severe injury that is a direct result of participating inany official intercollegiate competition, practice or team sanctioned training session (excludes pre-existing and overuseinjuries). The NCAA prohibits a school from providing coverage or paying bills for treatment of any condition that is notsustained during intercollegiate participation. These bills are the student-athlete’s responsibility. Additionally, the NCAAsponsors a Catastrophic Injury Insurance Program, which covers the student-athlete who is catastrophically injured whileparticipating in a covered intercollegiate athletic activity. The policy has a 90,000 deductible and provides benefits inexcess of any other valid and collectible insurance.The athletic accident insurance plan provided by North Park is an excess policy, which means it only covers what yourprimary insurance does not after a 500 deductible is met. The 500 deductible is a disappearing deductible, whichmeans it can be satisfied by primary insurance payments. For example, if the primary carrier pays at least 500 towardscare for an injury, no deductible is applied. If the student-athlete’s primary insurance pays anything less than 500, thatamount is applied to the 500 deductible and the difference will be the responsibility of the student-athlete. In otherwords, not only are you responsible for all medical bills outside of athletic injuries but you are also responsible for the first 500 of bills incurred from a sports injury, either out-of-pocket or through your primary insurance policy.You must also show proof you are covered under a primary insurance plan before participating in any North Parkintercollegiate sport. Here are your options:1.2.3.4.Your parents’ policy if you are under 26 years old and are still listed as a dependent, or a spouse’s policyIndividual insurance plans available on the market, independent from the Affordable Care Act and MedicaidAffordable Care Act or Medicaid. Call 1-800-318-2596 or visit www.healthcare.gov/young-adults to check eligibilityInternational students can enroll in a plan via North Park. Call NPU International Affairs Office at 773-244-5571You must be protected in one of these ways. Student-athletes at North Park are not allowed to participate in any way untilyour insurance information is on file, including a front/back copy of your insurance card. This copy will allow our SportsMedicine staff to expedite the approval process of certain diagnostic tests if needed (i.e. MRI, specialist, etc.).HMO and Similar PlansIf a student-athlete is covered under an HMO plan (or similar policy) from outside of Illinois or the Chicagoland area, it isimportant that you are familiar with your insurance coverage while attending school away from home. These plans oftenrequire all non-emergent care be directed through your primary care physician, which can be very difficult if you are faraway. Our excess policy provides secondary coverage only if the student-athlete follows the primary plan’s procedures,which means you would have to go home to see your physician for all care or approval for diagnostic testing or othermedical care. We strongly recommend talking with your insurance company to be knowledgeable about your coveragewhile at North Park. Often times they can make recommendations or changes to your policy to accommodate your timeaway from home. The following is information about the facilities we primarily use for care, which can be shared with yourinsurance company and they could possibly pre-approve these providers, which would bypass the need to see yourprimary care doctor from home. While away from home, you could also list our Medical Director as your primary carephysician, if permitted and covered by your plan.Dr. Poonam Thaker – Medical DirectorPresence Resurrection Family Practice/Sports Medicine7447 W. Talcott Ave, Suite 182, Chicago, IL 60631Swedish Covenant HospitalEmergency Room/Outpatient Diagnostics5140 N. California Ave, Chicago, IL 60625If you have any questions place contact Head Athletic Trainer Eric McQuaid at emcquaid@northpark.edu.Thank you,North Park Athletic Training Services
First Agency, Inc.North Park University5071 West H Avenue3225 W Foster Ave, Box 25Kalamazoo, MI 49009-8501Chicago, IL 60625*****PLEASE PROVIDE A COPY OF YOUR INSURANCE CARDS (FRONT & BACK)*****Note: Complete all blanks on this form. Failure to complete all blanks will result in claims processing delays.If information is not applicable, indicate the reason it is not (e.g., deceased, divorced, unknown).Name of AthleteSportSchool ID # (if known)Date of BirthCollege AddressCell Phone()Home AddressHome Phone()CityStateFATHER/GUARDIAN INFORMATIONZipMOTHER/GUARDIAN ate of BirthDate of yerAUTHORIZATION - To Permit Use and Disclosure of Health InformationThis Authorization was prepared by First Agency, Inc. for purposes of obtaining information necessary to process a claimfor benefits.Upon presentation of the original or a photocopy of this signed Authorization, I authorize, without restriction (exceptpsychotherapy notes), any licensed physician, medical professional, hospital or other medical-care institution, insurancesupport organization, pharmacy, governmental agency, insurance company, group policyholder, employer or benefit planadministrator to provide First Agency, Inc. or an agent, attorney, consumer reporting agency or independent administrator,acting on its behalf, all information concerning advice, care or treatment provided the patient, employee or deceased namedbelow, including all information relating to, mental illness, use of drugs or use of alcohol. This Authorization also includesinformation provided to our health division for underwriting or claim servicing and information provided to any affiliatedinsurance company on previous applications. If this Authorization is for someone other than myself, that individual has givenme the authority to act on his/her behalf as explained below.I understand that I have the right to revoke this Authorization, in writing, at any time by sending written notification to myagent or to us at the above address. I understand that a revocation will not be effective to the extent we have relied on theuse or disclosure of the protected health information or if my Authorization was obtained as a condition to determine myeligibility for benefits. Revocation requests must be sent in writing to the attention of the Claims Supervisor.I understand that First Agency, Inc. may condition payment of a claim upon my signing this authorization, if the disclosure ofinformation is necessary to determine the level or validity of the claim payment. I also understand, once information isdisclosed to us pursuant to this Authorization, the information will remain protected by First Agency, Inc. in accordance withfederal or state law.I understand that I or my authorized representative is entitled to receive a copy of this authorization uponrequest. This Authorization is valid from the date signed for the duration of the claim.Name of Claimant (please print)Signature of Claimant (if claimant is 18 or older)Name of Authorized Representative, or Next of Kin (please print)DateSignature of Authorized Representative of Next of KinDateRelationship of Authorized Representative or Next of Kin to Claimant6
Medical Exception Documentation Reporting Form to Support theDiagnosis of Attention Deficit Hyperactivity Disorder (ADHD) and Treatmentwith Banned/Restricted Stimulant MedicationYou may skip this form if you do not take any medication for ADHD or similar disorder.North Park University governed by the rules and regulations of the NCAA. As a member of the NCAA, studentathletes are subject to drug testing programs set forth by the NCAA in addition to North Park University’sinstitutional policy. The most common medications used to treat ADHD are Ritalin (methylphenidate) and Adderall(dextroamphetamine and amphetamine), which are restricted under the NCAA class of stimulants. The NCAA andNPU recognize the need for properly diagnosed individuals to use these medications to support their academicsand their general health. However, we also recognize banned substances can be harmful to student-athletes andmay create an unfair advantage of competition. Therefore, it is required by the NCAA and NPU to haveappropriate medical information on file in advance of undergoing drug testing.The intent of this policy is to confirm the student-athlete has undergone a clinical assessment to diagnose ADHD,is being monitored routinely for the use of stimulant medication, and has a current prescription on file in order tobe approved for a medical exception to the banned drug policy.Please use this form to assist in obtaining the required documentation supporting medical need for treatment ofADHD with stimulant medication. The athletic training staff will file this information with the rest of the studentathlete’s medical record and it will be produced to the NCAA in the event the student-athlete tests positive for thebanned medication.More information can be found at itions/adhd-and-studentathlete. Other specific questions about this policy can be directed to the Head Athletic Trainer: Eric McQuaid,773.244.5701 or emcquaid@northpark.edu.Student-Athlete’s Name:Date of Birth:Contact phone number: ( )The following items are required from your healthcare provider treating your ADHD:Treating Physician (print name):Specialty:Office Address/Phone:Physician documentation (letter, medical notes) must include the following information: Diagnosis, date of last clinical evaluation Medication(s) and dosage, copy of most recent prescription Follow-up orders Written summary of comprehensive clinical evaluation. The evaluation can and should be completed by aclinician capable of meeting the requirements detailed above.7
North Park University Department of AthleticsDrug Education and Testing Program Consent to Policy FormI certify the following:(Student-Athlete Name)1. I have read and understand the North Park University Drug Education and Testing Program(“Program”). I accept all conditions of the Program as a condition for my eligibility to participate inthe North Park University Intercollegiate Athletics Program. A copy of the program is locatedonline at www.northpark.edu/athletics under the “Student Athlete Handbook”2. I understand that selection for testing may be based on random selection, reasonable suspicionof misuse/abuse, and/or other reasonable cause.3. I understand that the Program prohibits the use of illegal drugs, or drug abuse in any manner, andthat a positive test for banned substances under the Program will result in the sanctions set forthin the Program.4. I consent to the release of any testing results to an authorized representative as outlined in theProgram for the purposes of determining whether a violation of the Program has occurred. Inaddition to this consent, I understand that in the event of a positive test I will be required to notifymy parent(s)/guardian in the presence of the Director of Athletics and/or their designee.5. I understand that if I test positive for any banned substance that I will be required to participate inan evaluation(s) by NPU Counseling services and/or Team Physician.6. I understand that I will be required to follow any recommendation for follow-up or treatmentresulting from an evaluation and any expense occurred from an outside agency will be at my ownresponsibility.7. I agree to cooperate in providing consent to any counseling services or agency to release to theDrug Program Administrator an evaluation and recommendations for follow-up or treatment.Signature of Student-Athlete: Date:Cell Phone #:Parent Signature(Required if under 18 years old)8
North Park University Intercollegiate AthleticsAthletic Training ServicesSickle Cell Trait Information FormThis form is for student-athletes new to North Park only. Returners can skip.What is Sickle Cell? Sickle cell trait is an inherited condition involving the oxygen-carrying protein, hemoglobin, in red blood cells This is a common condition, over three million Americans have sickle cell trait Most predominant in African Americans and those of Mediterranean, Middle Eastern, Indian, Caribbean,South and Central American ancestry – however, persons of all races and ancestry may test positive During intense, sustained exercise the abnormal hemoglobin can cause the blood cells to change shape fromround to quarter-moon shaped, otherwise known as “sickling”What are the risks? As red blood cells sickle they become inflexible and sticky, blocking adequate blood flow to the tissues,organs and muscle This blockage is associated with a condition known as exertional rhabdomyolysis, which is the breakdown ofoxygen-starved muscle – this can progress to sudden collapse, organ failure and death if mismanaged ormistreated Other factors that can increase the risk, or worsen the complications, associated with sickle cell trait include:high heat-humidity, dehydration, altitude, general illness and asthma.Can student-athletes participate if they have the sickle cell trait? Having sickle-cell trait does not exclude an athlete from participation, but does require precautions in order toprotect against risks associatedHow do I fulfill the Sickle Cell Trait testing requirement?1. Submit results of previous sickle-cell trait testing2. Undergo sickle-cell trait testing with physician or through Swedish Covenant Hospital and submit results3. Sign a waiver acknowledging the risks of not knowing your sickle-cell trait statusYou must choose one of these three options before you can compete in any way as a student-athlete at North Park.This includes pre-season and off-season training.More Information from the NCAA:http://www.youtube.com/watch?v EiEpmZLLcuM&feature youtu.behttp://www.youtube.com/watch?v lbFWP39tF1A&feature youtu.be9
North Park University Intercollegiate AthleticsAthletic Training ServicesSickle Cell Trait Compliance FormThis form is for athletes new to North Park only. Returners can skip.After reviewing the North Park Sickle Cell Trait Education Form and other NCAA Educational Materials, I have chosenthe following method to remain in compliance with NCAA Division III regulations regarding sickle-cell trait status andtesting:CHECK ONEI will provide documentation of my sickle cell trait status from previous testing (bring documentation with youto your sport’s reporting day, or email to Head Athletic Trainer Eric McQuaid @ emcquaid@northpark.eduI will undergo sickle-cell testing through Swedish Covenant Hospital (available when you arrive to campus). Iunderstand that if my health insurance does not cover the cost of this test, the cost will be charged to myNorth Park University student account ( 10.00), and I will be responsible for paying the fee. If I have pendingfinancial aid on my student account, I authorize North Park University to apply my aid to this fee.I, , understand and acknowledge that the NCAA and North ParkUniversity Department of Athletics recommends that all student-athletes have knowledge of their sickle celltrait status. Additionally, I have read and fully understand the aforementioned facts about sickle cell traittesting. Recognizing that my true physical condition is dependent upon an accurate medical history and a fulldisclosure of any symptoms, complaints, prior injuries, aliments and/or disabilities experienced, I herebyaffirm that I have fully disclosed in writing any prior medical history and/or knowledge of sickle cell trait statusto the North Park University Athletic Training Staff. I do not wish to undergo sickle cell trait testing and Ivoluntarily agree to release, discharge, indemnify, and hold harmless North Park University, its officers,employees, and agents from any and all costs, liabilities, expenses, claims demands, or causes of action onaccount of any loss or personal injury that might result from my non-compliance with the recommendation ofthe NCAA and the North Park University Department of Athletics. I have read and signed this document withfull knowledge of its significance.Student-Athlete (print) Sport:Student-Athlete (sign) Date:Parent/Guar
Participation in intercollegiate athletics involves the inherent risk of injury, the severity of which may range from minor to catastrophic, or from temporary impairment to permanent disability, including paralysis or death. Since the participation in sports requires an acceptance of the risk of injury by the student-athlete, he or she
