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North Park UniversityIntercollegiate Athletics Pre-Participation PacketFor Returning Student-AthletesPrior to beginning another season within North Park University Intercollegiate Athletics, the following Pre-ParticipationPacket needs to be completed and reviewed by the Athletic Training Staff. Please use the following chart as a checklistto 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: 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 6: 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 treating physician. This must be done every year of participation. If thisdoes not apply to you, leave this form blank.Page 7: 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 8: 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 9: 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 EACH ACADEMIC YEAR.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 AthleticsDepartment of Athletic TrainingInformed 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 AthleticsDepartment of Athletic TrainingAssumption 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 andconsent might be re-disclosed by the recipient under circumstances such that the information will nolonger protected 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 or procedure with respect to your physical or mental condition or functional status affectingyou or the structure or function of your body, (c) any sale or dispensing of a drug, device or equipmentto you in accordance with a prescription or otherwise, or (d) any past, present or future financial rightsor obligations of any person, entity, organization or governmental body with regard to the forgoingservices and supplies. For purposes of this authorization and consent the information described in thepreceding sentence 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 ordelivery of any services or supplies, directly or indirectly, by any person, entity, organization orgovernmental body in furtherance of any preventive, diagnostic, therapeutic, rehabilitative,maintenance, or palliative care, or any counseling, service, assessment or procedure with respect toyour physical or mental condition or functional status affecting you or the structure or function of yourbody; (ii) related to any past present or future financial rights or obligations of any person, entity,organization or governmental body with regard to the foregoing services and supplies; or (iii) related toyour eligibility to participate in athletic activities or programs organized, sponsored, or otherwisesupported by North Park University.4.Persons to Whom You Authorize Your Health Care Information to be Disclosed. In furtheranceof the purposes described in the preceding paragraph, you authorize North Park University and itsemployed or otherwise affiliated physicians, athletic trainers, coaches, health care, and administrativepersonnel to disclose Your Health Care Information to each other and to any person, entity,organization or governmental body that: (i) renders or delivers, or which has or is expected to render ordeliver, directly or indirectly, any services or supplies in furtherance of any preventive, diagnostic,therapeutic, rehabilitative, maintenance, or palliative care, or 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, (ii) has, has had, or may have, any financial rights or obligations withrespect to the foregoing services and supplies, or (iii) provides oversight or requires reporting withrespect to athletic activities or programs organized, sponsored, or otherwise supported by North ParkUniversity.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 ofthis authorization and consent.Name of student-athlete (print)DateSignature of student-athleteIf applicable: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
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 INFORMATIONFather's NameMother's NameDate 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 Claimant5
Medical Exception Documentation Reporting Form to Support theDiagnosis of Attention Deficit Hyperactivity Disorder (ADHD) and Treatmentwith Banned 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.6
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 participatein the North Park University Intercollegiate Athletics Program. A copy of the program islocated online 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,and that a positive test for banned substances under the Program will result in the sanctions setforth in 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 tonotify my 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 participatein an 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 myown responsibility.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:Contact Phone #:Parent Signature(Required if under 18 years old)7
North Park University Intercollegiate Athletics Health History FormAdapted from AAFP, et al. 2010 (Permission is granted to reprint for noncommercial, educational purposes with acknowledgement.)Note: This form is to be filled out by the student-athlete and parent prior to seeing the physician.Name: Date of Birth: Sex: Age: Sport(s):Medications (including supplements): Allergies:Explain any “YES” answers in the lower right box, in detail. Circle questions you don’t know the answers to.GENERAL QUESTIONSYesNo34. Have you ever had a head injury or concussion?1. Has a doctor ever denied or restricted your participation in sports for anyreason?35. Have you ever had a hit or blow to the head that causedconfusion, prolonged headache or memory problems?2. Do you have any ongoing medical conditions? (asthma, anemia, diabetes,infections, etc.)36. Do you have a history of seizure disorder?3. Have you ever spent the night in a hospital?37. Do you have headaches with exercise?4. Have you ever had surgery?HEART HEALTH QUESTIONS ABOUT YOU/YOUR FAMILYYesNo5. Have you ever passed out or nearly passed out during or after exercise?6. Have you ever had discomfort, pain, tightness, or pressure in your chestduring exercise?38. Have you ever had numbness, tingling, or weakness in yourarms or legs after being hit or falling?39. Ever been unable to move your arms/legs after being hit orfalling?40. Have you ever become ill while exercising in the heat?41. Do you get frequent muscle cramps while exercising?7. Does your heart ever race or skip beats during exercise?42. Do you or someone in your family have sickle cell trait ordisease?8. Has a doctor ever told you that you have any heart problems? (bloodpressure, cholesterol, murmur, infection, etc.)43. Had any problems with your eyes or vision?9. Has a doctor ever ordered a test for your heart? (ECG/EKG, echo, etc.)44. Have you had any eye injuries?10. Do you get lightheaded or feel more short of breath than expected duringexercise?45. Do you wear glasses or contacts?11. Have you ever had an unexplained seizure?46. Do you wear protective eyewear, such as goggles/face shield?12. Do you get more tired or short of breath more quickly than your friendsduring exercise?13. Has any family member or relative died of heart problems or had anunexpected/unexplained sudden death before age 50?14. Does anyone in your family have hypertrophic cardiomyopathy, Marfansyndrome, arrhythmogenic right ventricular cardiomyopathy, long QTsyndrome, short QT syndrome, Brugada syndrome, or catecholaminergicpolymorphic ventricular tachycardia?15. Anyone in your family have a heart problem, pacemaker, implanteddefibrillator?16. Has anyone in your family had unexplained fainting, unexplained seizures,or near drowning?BONE AND JOINT QUESTIONS17. Have you ever had an injury to a bone, muscle, ligament, or tendon thatcaused you to miss a practice or a game?47. Do you worry about your weight?48. Are you trying to or has anyone recommended that you gain orlose weight?49. Are you on a special diet or do you avoid certain types of foods?50. Have you ever had an eating disorder?51. Do you have any concerns that you would like to discuss with adoctor?YesNoFEMALES ONLYYes52. Have you ever had a menstrual period?18. Have you ever had any broken or fractured bones or dislocated joints?53. How old were you when you had your first menstrual period?19. Have you ever had an injury that required x-rays, MRI, CT scan, injections,therapy, a brace, cast or crutches?54. How many periods have you had in the last 12 months?20. Have you ever had a stress fracture?21. Have you ever had an x-ray for neck instability or atlantoaxial instability?22. Do you regularly use a brace, orthotics, or other assistive device?23. Do you have a bone, muscle, or joint injury that bothers you?24. Do any joints become painful, swollen, feel warm, or look red?25. Do you have any history of arthritis or connective tissues disease?MEDICAL QUESTIONS26. Do you cough, wheeze, or have difficulty breathing during or afterexercise?27. Have you ever used an inhaler or taken asthma medicine?28. Is there anyone in your family who has asthma?29. Were you born without or are you missing a kidney, an eye, a testicle, yourspleen or any other organ?30. Do you have groin pain/painful bulge?31. Have you had infections mononucleosis (mono) within the last month?32. Do you have any rashes, pressure sores, or other skin problems?NoYesNoExplain “YES” answers here:33. Have you had a herpes or MRSA skin infection?I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.Signature of Student-AthleteDate / /Signature of Parent/Guardian (if student-athlete under 18)8
North Park University Intercollegiate Athletics Physical Examination FormAdapted from AAFP, et al. 2010 (Permission is granted to reprint for noncommercial, educational purposes with acknowledgement.)THIS EXAMINATION MUST BE COMPLETED BY AN M.D OR D.O!No PA-C, NP, CNS, or other clinician per NCAA ruleStudent-Athlete Name Date of Birth / / Sport(s)HeightBlood PressureBody Fat % (optional):MEDICALWeightHeart RatePupils: EQUAL UNEQUALMale / FemaleVision R 20/L 20/Corrected Vision? YES NONORMALABNORMAL FINDINGSNORMALABNORMAL FINDINGSAppearanceEyes/Ears/Nose/ThroatLymph NodesHeartPulsesLungsAbdomenGenitourinary (males g/AnkleFoot/ToesFunctionalCleared for all sports without restrictionCleared for all sports without restriction with recommendations for further evaluation or treatment forNot clearedPending further evaluationFor any sportsFor certain sportsReasonRecommendationsI have examined the above-named student and completed the preparticipation physical evaluations. The athlete does not present apparent clinicalcontraindications to practice and participate in the sport(s) outlined above. A copy of the physical exam is on record in my office and can be madeavailable to the school at the request of the school and the athlete (and parents/guardian if athlete is under 18 years of age). If conditions arise afterthe athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequencesare completely explained to the athlete (and parents/guardian if athlete is under 18 years of age).Name of Physician (print) Date / /Signature of Physician MD or DO (circle)Address Phone9
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
