Colorado School of Mines Athletics
Forms Check List
Returning Student-Athletes
2016-17
Welcome back to Colorado School of Mines Athletics! The following are instructions for
completing the necessary medical and insurance forms to allow you to participate in varsity
athletics.
Please type directly in all pdf forms (hand written forms will not be accepted), print all
forms and sign where required – including parent / guardian signatures.
All forms must be mailed and received in our office by August 1, 2016:
Colorado School of Mines
Athletic Training
1500 Illinois Street
Golden, CO 80401
1.
2.
3.
4.
5.
6.
Medical History Questionnaire
Acknowledgement of Risk
Injury & Illness Reporting Policy
Sickle Cell Trait Testing & Waiver
Acknowledgement of Insurance Requirements
Copy of front and back of current health insurance card
You must complete the CSM Student Health Benefit Plan, SHBP, Enrollment/Waiver process
on Trailhead or the premium will be billed to your student account.
For questions, please contact: Jennifer McIntosh 303-273-3375
Andy Vanous
303-273-3575
Jacob Pope
303-384-2084
Jessica Hoyt
303-384-2556
John Thomas
303-273-3375
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
Remember, we must receive all documents before you will be cleared to report to your
respective sport including team meetings, tryouts, practices or competitions.
Please type directly in all pdf forms (hand written forms will not be accepted), print all
forms and sign where required – including parent / guardian signatures.
All forms must be mailed and received in our office by August 1, 2016.
Colorado School of Mines- Athletic Training
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW
YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Explanation of Forms. Colorado School of Mines- Athletic Training handles medical information about you, and law regulates how that information is
handled. To comply with the law, Colorado School of Mines- Athletic Training asks you to receive this notice and, in some circumstances, to sign an
authorization form.
Colorado School of Mines- Athletic Training is allowed by law to use and disclose information about you for the purposes essential to providing care
(treatment, payment collection, and operating Colorado School of Mines- Athletic Training).
An authorization allows Colorado School of Mines- Athletic Training to use and disclose information about you for any other reason that is indicated by you
in the authorization. Colorado School of Mines- Athletic Training may not refuse to treat you for refusing to sign the authorization. Other rules about your
rights regarding medical information are described in this notice.
Types of Uses and Disclosures. Medical information about you may be used or disclosed by Colorado School of Mines- Athletic Training for treatment,
payment, and health care operations. Treatment includes consultation, diagnosis, provision of care, and referrals. Payment includes all those things
necessary for billing and collection, such as claims processing. Health care operations include things Colorado School of Mines- Athletic Training does to
assess quality of care, train staff, and manage Colorado School of Mines- Athletic Training business. Some examples of disclosures and use are as
follows:
•
Example of Treatment Disclosure. Colorado School of Mines- Athletic Training may disclose medical information about you to your treating physician,
a hospital or other providers to help them diagnose and treat an injury or illness.
•
Example of Payment Disclosure. Colorado School of Mines- Athletic Training may disclose medical information about you when health plans or
insurers, Medicare, Medicaid, or other payors require the information before paying for your health care services.
•
Example of Health Care Operations Use. Colorado School of Mines- Athletic Training may use medical information about you when it hires new staff
whose training requires information about the medical needs of our patients.
Colorado School of Mines- Athletic Training may also contact you to provide appointment reminders or cancellations or to notify you of follow up tests or
procedures that may be required. We may leave this limited information on an answering machine or voicemail at the numbers provided by you unless you
request a restriction regarding this method of communicating your protected health information.
Other Uses and Disclosures. We may use or disclose your protected health information in the following situations without your authorization. These
situations include:
•
As Required By Law. We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or
disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.
•
Public Health. We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted
by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also
disclose your protected health information to another government agency that is collaborating with the public health authority.
•
Communicable Diseases. We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a
communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
•
Health Oversight. We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits,
investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system,
government benefit programs, other government regulatory programs and civil rights laws.
•
Abuse or Neglect. We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child
abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or
domestic violence to the governmental entity or agency authorized to receive such information.
•
Food and Drug Administration. Colorado School of Mines- Athletic Training may disclose a patient’s health information to a person subject to the
jurisdiction of the Food and Drug Administration if that person has responsibility to report adverse events, product defects or problems, or biologic
product deviations; to track products; to enable product recalls, repairs or replacements; or, to conduct post marketing surveillance.
•
Legal Proceedings. We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of
a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery
request or other lawful process.
•
Law Enforcement. We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement
purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for
identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the
event that a crime occurs on the premises of Colorado School of Mines- Athletic Training, and (6) medical emergency (not on Colorado School of
Mines- Athletic Training premises) and it is likely that a crime has occurred.
•
Coroners, Funeral Directors, and Organ Donation. We may disclose protected health information to a coroner or medical examiner for identification
purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose
protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out his duties. We may disclose
such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue
donation purposes.
•
Research. We may disclose your protected health information to researchers when the research has been approved by an institutional review board
that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
•
Criminal Activity. Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or
disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public
•
Military Activity and National Security. When the appropriate conditions apply, we may use or disclose protected health information of individuals who
are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination
by the Department of Veterans Affairs of eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services.
We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities,
including for the provision of protective services to the President or others legally authorized.
•
Workers’ Compensation. Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and
other similar legally established programs.
•
Inmates. We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or
received your protected health information in the course of providing care to you.
•
Required Uses and Disclosures. Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health
and Human Services to investigate or determine our compliance with the law.
Others Involved in Your Healthcare. Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you
identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a
disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use
or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for
your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private
entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
Authorized Uses and Disclosures. Additional uses and disclosure may be made if you have given written authorization, which may be revoked at any
time in writing delivered to the Director, except to the extent Colorado School of Mines- Athletic Training acted in reliance on the authorization.
Restrictions. You have the right to request restrictions on the use and disclosure of medical information about you; however, Colorado School of MinesAthletic Training will only be bound by the restrictions if Colorado School of Mines- Athletic Training notifies you that it agrees with them.
Confidentiality. You have the right to have Colorado School of Mines- Athletic Training use only confidential means of communicating with you about
medical information. This means you may have information delivered to you at a certain time or place, or in a manner that keeps your information
confidential.
Access. You have the right to see and receive a copy of information about you kept by Colorado School of Mines- Athletic Training under most
circumstances.
Amendment. You have the right to have Colorado School of Mines- Athletic Training amend its records of information about you. Colorado School of
Mines- Athletic Training may refuse to amend information that is accurate, that was created by someone else, or is not disclosable to you.
Accounting. You have the right to see a list of certain disclosures of medical information about you by Colorado School of Mines- Athletic Training, which
includes the purposes and recipients of the information.
Copy. You have the right to receive a paper copy of this notice.
Privacy Notice. Colorado School of Mines- Athletic Training is required by law to keep medical information about you private and to give you this notice.
Colorado School of Mines- Athletic Training must abide by this notice; however, we reserve the right to amend this notice and make such change
applicable to all medical information maintained in our facility. We will provide a revised notice to patients by posting the new notice in the waiting room of
the student health center.
Complaints. You may complain to Colorado School of Mines- Athletic Training if you believe your privacy rights have been violated by giving a written
complaint to the Privacy Officer at Colorado School of Mines- Athletic Training 1500 Illinois St. Golden, CO 80401. You may also complain to the Secretary
of the U.S. Department of Health and Human Services. Colorado School of Mines- Athletic Training will not retaliate against you for making a complaint.
Effective Date. This notice is effective from April 14, 2004 until revised by Colorado School of Mines- Athletic Training.
CONCUSSION
A fact sheet for student-athletes
What is a concussion?
A concussion is a brain injury that:
• Is caused by a blow to the head or body.
– From contact with another player, hitting a hard surface such
as the ground, ice or floor, or being hit by a piece of equipment
such as a bat, lacrosse stick or field hockey ball.
• Can change the way your brain normally works.
• Can range from mild to severe.
• Presents itself differently for each athlete.
• Can occur during practice or competition in ANY sport.
• Can happen even if you do not lose consciousness.
How can I prevent a concussion?
Basic steps you can take to protect yourself from concussion:
• Do not initiate contact with your head or helmet. You can still get
a concussion if you are wearing a helmet.
• Avoid striking an opponent in the head. Undercutting, flying
elbows, stepping on a head, checking an unprotected opponent,
and sticks to the head all cause concussions.
• Follow your athletics department’s rules for safety and the rules of
the sport.
• Practice good sportsmanship at all times.
• Practice and perfect the skills of the sport.
What are the symptoms of a
concussion?
You can’t see a concussion, but you might notice some of the symptoms
right away. Other symptoms can show up hours or days after the injury.
Concussion symptoms include:
• Amnesia.
• Confusion.
• Headache.
• Loss of consciousness.
• Balance problems or dizziness.
• Double or fuzzy vision.
• Sensitivity to light or noise.
• Nausea (feeling that you might vomit).
• Feeling sluggish, foggy or groggy.
• Feeling unusually irritable.
• Concentration or memory problems (forgetting game plays, facts,
meeting times).
• Slowed reaction time.
Exercise or activities that involve a lot of concentration, such as
studying, working on the computer, or playing video games may cause
concussion symptoms (such as headache or tiredness) to reappear or
get worse.
What should I do if I think I have a concussion?
Don’t hide it. Tell your athletic trainer and coach. Never ignore a blow to the head. Also,
tell your athletic trainer and coach if one of your teammates might have a concussion.
Sports have injury timeouts and player substitutions so that you can get checked out.
Report it. Do not return to participation in a game, practice or other activity with
symptoms. The sooner you get checked out, the sooner you may be able to return to play.
Get checked out. Your team physician, athletic trainer, or health care professional
can tell you if you have had a concussion and when you are cleared to return to play.
A concussion can affect your ability to perform everyday activities, your reaction time,
balance, sleep and classroom performance.
Take time to recover. If you have had a concussion, your brain needs time to heal. While
your brain is still healing, you are much more likely to have a repeat concussion. In rare
cases, repeat concussions can cause permanent brain damage, and even death. Severe
brain injury can change your whole life.
It’s better to miss one game than the whole season.
When in doubt, get checked out.
For more information and resources, visit www.NCAA.org/health-safety and www.CDC.gov/Concussion.
Reference to any commercial entity or product or service on this page should not be construed
as an endorsement by the Government of the company or its products or services.
A Fact Sheet for Student-athletes
SICKLE CELL TRAIT
What is
sickle
cell trait?
Sickle cell trait is not a
disease. Sickle cell trait is the
inheritance of one gene for
sickle hemoglobin and one
for normal hemoglobin. Sickle
cell trait will not turn into the
disease. Sickle cell trait is a
life-long condition that will not
change over time.
u During intense exercise, red blood cells containing the
sickle hemoglobin can change shape from round to
quarter-moon, or “sickle.”
u Sickled red cells may accumulate in the bloodstream
during intense exercise, blocking normal blood flow to
the tissues and muscles.
u During intense exercise, athletes with sickle cell trait
have experienced significant physical distress, collapsed
and even died.
u Heat, dehydration, altitude and asthma can increase the
risk for and worsen complications associated with sickle
cell trait, even when exercise is not intense.
u Athletes with sickle cell trait should not be excluded from
participation as precautions can be put into place.
Do you
know if you
have sickle
cell trait?
People at high risk
for having sickle cell trait
are those whose ancestors
come from Africa, South or
Central America, India, Saudi
Arabia and Caribbean and
Mediterranean countries.
u Sickle cell trait occurs in about 8 percent of the U.S.
African-American population, and between one in 2,000 to
one in 10,000 in the Caucasian population.
u Most U.S. states test at birth, but most athletes with sickle
cell trait don’t know they have it.
u The NCAA recommends that athletics departments confirm
the sickle cell trait status in all student-athletes.
u Knowledge of sickle cell trait status can be a gateway
to education and simple precautions that may prevent
collapse among athletes with sickle cell trait, allowing
you to thrive in your sport.
how can i prevent
a collapse?
u Know your sickle cell trait status.
u Engage in a slow and gradual preseason
conditioning regimen.
u Build up your intensity slowly while training.
u Set your own pace. Use adequate rest and recovery
between repetitions, especially during “gassers” and
intense station or “mat” drills.
u Avoid pushing with all-out exertion longer than two to
three minutes without a rest interval or a breather.
u If you experience symptoms such as muscle pain,
abnormal weakness, undue fatigue or breathlessness,
stop the activity immediately and notify your athletic
trainer and/or coach.
u Stay well hydrated at all times, especially in hot and
u Maintain proper asthma management.
u Refrain from extreme exercise during acute illness,
if feeling ill, or while experiencing a fever.
u Beware when adjusting to a change in altitude, e.g., a rise
in altitude of as little as 2,000 feet. Modify your training and
request that supplemental oxygen be available to you.
u Seek prompt medical care when experiencing
unusual physical distress.
humid conditions.
u Avoid using high-caffeine energy drinks or supplements,
or other stimulants, as they may contribute to dehydration.
For more information and resources,
visit www.NCAA.org/health-safety
Colorado School of Mines Athletics
Medical History Questionnaire
2016-17
This is a confidential record of your medical history. Information contained herein will not be released to anyone
except CSM Team Physicians and CSM Athletic Trainers until you have authorized us to do so.
You understand that this information may be used and disclosed by CSM Team Physicians and CSM Athletic Trainers
to provide emergency medical care to you without your express authorization.
I give permission for the CSM Team Physicians and CSM Athletic Trainers to perform evaluations and treatment for
injuries incurred in my sport.
I understand the medical expenses incurred for medical care are my responsibility and are not the responsibility of
CSM Athletic Trainers, CSM Athletic Department or treating physicians.
I understand that the results of this questionnaire may result in further evaluation by CSM Team Physicians before I
am cleared to participate. I will be financially responsible for any additional evaluations or tests as needed.
Today’s Date:
CSM E-Mail:
CSM CWID:
Last Name:
First Name:
Middle Initial:
DOB (mm/dd/yyyy):
Age:
Marital Status: Single
Sport:
Eligibility Year:
ALLERGIES – Are you allergic to any of the following:
Yes
No
Medicines
Yes
No
Latex
please list:
Yes
No
Adhesive Tape
Yes
No
Stinging Insects
Yes
No
Pollens, Dust, Grass, Natural Allergens
Yes
No
Food
Yes
No
Detergents
please list:
Yes
No
Other:
MEDICATIONS AND SUPPLEMENTS – List any medications or supplements you are currently taking:
MEDICATION / SUPPLEMENT
NAME
REASON TAKING
DATE BEGAN TAKING
FAMILY HISTORY – Has any family member or blood relative:
Yes
No
Died of heart problems or had an unexpected or unexplained sudden death before age 50 (including drowning,
unexplained car accident or sudden infant death syndrome)?
Yes
No
Have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT
syndrome, short QT syndrome, Brugada syndrome or catecholaminergic polymorphic ventricular tachycardia?
Yes
No
Have a heart problem, pacemaker or implanted defibrillator?
Yes
No
Had unexplained fainting, unexplained seizures or near drowning?
rev. May 2013
1 of 4
STUDENT-ATHLETE HISTORY
INJURIES – Have any of the following happened to you:
Provide specific information/details with any “Yes” answers. Attach additional documentation or medical records where necessary.
List all ligament sprains, muscle strains, joint dislocations, stress fractures and bone fractures you’ve had in the last 4 years:
Injury:
Body Part:
Side:
Date (mm/yyyy):
Injury:
Body Part:
Side:
Date (mm/yyyy):
Injury:
Body Part:
Side:
Date (mm/yyyy):
Injury:
Body Part:
Side:
Date (mm/yyyy):
List all surgeries/operations you’ve had in the past 4 years including date of surgery:
Yes
No
Have you ever been advised to have surgery which has not been done?
If “Yes” please explain:
Yes
No
Have you ever been advised by a physician not to participate in sports?
If “Yes” please explain:
Yes
No
Have you ever been hospitalized?
If “Yes” please explain:
Yes
No
Have you ever had an injury that required x-ray, MRI, CT, injection, therapy, brace, cast or crutches?
Yes
No
Have you ever had numbness, tingling or weakness in your arms or legs after being hit or falling?
Yes
No
Have you ever been unable to move your arms or legs after being hit or falling?
Yes
No
Concussion, head injury or blow to the head that caused confusion, headache or memory problem?
How many from athletics?
How many from other causes?
Most recent date (mm/yyyy)
Second date (mm/yyyy)
Third date (mm/yyyy)
Yes
No
Back pain, If “Yes” where?
Yes
No
Neck pain?
Yes
No
Have you ever been told you have had to have an x-ray for neck instability or atlantoaxial instability?
Yes
No
Stinger or burner, If “Yes” which side?
MEDICAL QUESTIONS
Yes
No
Have you ever been tested for Sickle Cell Trait?
Was the test positive? Yes
No
Yes
No
Were you born without or are you missing a kidney, eye, testicle, spleen or any other organ?
Yes
No
Do you have a groin pain or a painful bulge or hernia in the groin area?
Yes
No
Have you had infectious mononucleosis (mono) within the last month?
Yes
No
Do you have any rashes, pressure sores, or other skin problems?
Yes
No
Have you had a herpes or MRSA skin infection?
Yes
No
Do you have any ongoing medical conditions?
Yes
No
Have you ever been diagnosed with ADD or ADHD?
Yes
No
Have you ever had chicken pox or shingles?
Anemia
Diabetes
Infections
WOMEN ONLY
Date of last period (mm/dd/yyyy):
rev. May 2013
Regular? Yes
No
2 of 4
STUDENT-ATHLETE HISTORY (Continued)
GENERAL MEDICAL QUESTIONS – Do you have now or have you had any of the following:
HEAD
ORTHOPEDIC
Yes
No
Frequent / severe headache
Yes
No
Wear orthotics or brace
Yes
No
Headache during or after exercise
Yes
No
Recurrent neck pain
Yes
No
Difficulty Concentrating
Yes
No
Swollen, painful, warm or red joints
Yes
No
Migraines
Yes
No
Frequent muscle spasms or cramps
Yes
No
Juvenile arthritis
VISION
Yes
No
Vision Problems (double, spots, tunnel)
ENVIRONMENTAL
Yes
No
Any eye injuries or infection
Yes
No
Inability to tolerate heat
Yes
No
Do you wear glasses
Yes
No
Inability to tolerate cold
Yes
No
Do you wear contacts
Yes
No
Heat exhaustion
Yes
No
Wear contacts during competition
Yes
No
Heat stroke
Yes
No
Become ill while exercising in heat
HEARING
Yes
No
Hearing problems
NERVOUS
NOSE
Yes
No
Recurrent nosebleeds
Yes
No
Sinus trouble or infection
Yes
No
Pain in arms with or w/o being hit
Yes
No
Tingling or weakness in hands or feet
Yes
No
Dizziness with activity
GASTROINTESTINAL / URINARY
ORAL
Yes
No
Difficulty swallowing
Yes
No
Soreness or bleeding of gums
Yes
No
Coughed up blood
RESPIRATORY
Yes
No
Cough or wheeze during / after exercise
Yes
No
Difficulty breathing during / after exercise
Yes
No
Asthma or exercise induced asthma
Yes
No
Use an inhaler or take asthma medicine
Yes
No
Use an inhaler during exercise
Yes
No
Recurrent stomach pain/heartburn
Yes
No
Nausea or vomiting
Yes
No
Abdominal cramps
Yes
No
Pain with urinating
Yes
No
Blood or dark colored urine
Yes
No
Do you worry about your weight
Yes
No
Are you trying to gain or lose weight
Yes
No
Ever had an eating disorder
Yes
No
On a special diet or avoid certain food
WEIGHT
HEART HEALTH QUESTIONS
Yes
No
Have you ever passed out or nearly passed out during or after exercise?
Yes
No
Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
Yes
No
Does your heart ever race or skip beats (irregular beats) during exercise?
Yes
No
Has a doctor ever ordered a test for your heart (ECG/EKG, echocardiogram)?
Yes
No
Do you ever get lightheaded or feel more short of breath than expected during exercise?
Yes
No
Have you ever had an unexplained seizure?
Yes
No
Do you get more tired or short of breath more quickly than your friends during exercise?
Yes
No
Has a doctor ever told you that you have any heart problems? If yes check all that apply:
rev. May 2013
High blood pressure
Heart murmur
High cholesterol
Heart infection
Kawasaki disease
Other
3 of 4
Please include copies of all physicians’ reports regarding any surgery or hospitalization you have had in the past year.
I certify that all answers to the above statements are correct and true to the best of my knowledge.
I understand that Colorado School of Mines is not responsible for any previous medical conditions.
Signed: ___________________________________________________________
Parent / Guardian (Only if student is under 18)
Date: _____________________________
Signed: ___________________________________________________________
Student-Athlete
Date: _____________________________
Signed: ___________________________________________________________
CSM Athletic Trainer
Date: _____________________________
Contains portions of Preparticipation Physical Evaluation History Form © 2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine,
American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.
rev. May 2013
4 of 4
Colorado School of Mines Athletics
Acknowledgement of Risk
2016-17
Last Name:
First Name:
Middle Initial:
CWID:
This is a warning to you, as a student-athlete, of the risk you take by participating in varsity athletics at Colorado
School of Mines (CSM). By participating in any varsity athletics at CSM, you may sustain any one of the following
injuries. This list is not conclusive, as there are other injuries that can occur to you while participating in varsity
athletics at CSM. This acknowledgement, and list of injuries, is given to you to make you aware of the inherent
dangers and risks involved while participating in varsity athletics at CSM.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Head Injuries – Can result in permanent brain damage, coma and/or death.
Neck or Back Injuries – Can result in quadriplegia, paraplegia and/or death.
Strains – Completely torn, partially torn and/or stretched muscles, tendons or musculotendinous units.
Sprains – Completely torn, partially torn and/or stretched ligaments.
Contusions – Impact injuries.
Lacerations, Abrasions and Other Skin Injuries – Can result in infection.
Internal Organ Injuries – Can result in internal bleeding (i.e. ruptured spleen, kidney, liver, etc.).
Loss of Limb or Vital Organ
Cartilage – Damaged meniscus or cartilage in the joints of the body.
There are other injuries / illnesses that are not included in this list. This acknowledgement is to make you aware of
the seriousness and extent of various types of possible injuries that can occur to YOU while participating in varsity
athletics at CSM.
I have read the above and understand what it states. In consideration of Colorado School of Mines allowing me to
participate in varsity athletics, the undersigned Participant and Parent or Guardian, if appropriate, agree to hold
harmless, release, indemnify and forever discharge Colorado School of Mines, and its Board of Trustees, officers,
directors, employees, agents, and any persons acting on their behalf, as well as their heirs, executors and assigns
from and against any and all liability, claims, demands, costs and expenses (including attorneys’ fees) arising out of
or in any way connected with any bodily injury or property damage in any way relating to or arising out of my
participation in varsity athletics, even if the liability, claims, demands, costs and expenses may arise, in whole or in
part, out of the negligence or carelessness of the persons or entities mentioned above.
Signed: ________________________________________________ Date: _____________________________
Parent / Guardian (ONLY if student is under 18)
Signed: _________________________________________________ Date: _____________________________
Student-Athlete
rev. May 2013
Colorado School of Mines Athletics
Injury & Illness Reporting Policy
2016-17
Last Name:
First Name:
Middle Initial:
CWID:
I acknowledge that I have to be an active participant in my own healthcare. As such, I have the direct responsibility
for reporting all of my injuries and illnesses to the sports medicine staff of Colorado School of Mines (e.g., team
physician, athletic training staff). I recognize that my true physical condition is dependent upon as accurate medical
history and a full disclosure of any symptoms, complaints, prior injuries and/or disabilities experienced. I hereby
affirm that I have fully disclosed in writing any prior medical conditions and will also disclose any future conditions to
the sports medicine staff at Colorado School of Mines.
In the event of an injury during practice or competition, no matter how slight, I understand and agree that I must
report immediately to the Athletic Trainer of that sport. The Athletic Trainer will initiate the appropriate care.
Referral to Outside Health Care Providers: Referral to physicians, including specialists, nurse practitioners,
chiropractors, physical therapists and other health care providers will be made only by a Colorado School of Mines
Athletic Trainer. If you choose not to consult your assigned Athletic Trainer to obtain referral for outside services or
surgeries on an athletic related injury, the rehabilitation of that injury will not be the responsibility of the athletic
training staff.
Post-Injury/Illness Medical Clearance: Any athlete who sustains an injury or illness that requires outside medical
attention (Emergency Department, off-campus physician, etc.) needs a written letter of medical clearance from the
treating Physician. The athlete will not be medically eligible to participate until the Physician signed document is
presented to the athlete’s Athletic Trainer.
Concussion Reporting and Education: I further understand that there is a possibility that participation in my sport
may result in a head injury and/or concussion. I have been provided with education on head injuries and
understand the importance of immediately reporting symptoms of a head injury/concussion to a member of the
sports medicine staff.
By signing below, I acknowledge that my institution has provided me with specific educational materials on what a
concussion is and given me an opportunity to ask questions about areas and issues that are not clear to me on this
issue.
I have read the above and agree that the statements are accurate.
Signed: ________________________________________________
Parent / Guardian (ONLY if student is under 18)
Date: ____________________
Signed: ________________________________________________
Student-Athlete
Date: ____________________
rev. May 2013
Colorado School of Mines Athletics
Acknowledgement of Insurance Requirements
2016-17
Last Name:
First Name:
Sport:
Middle Initial:
DOB (mm/dd/yyyy):
CWID:
Eligibility Year:
This form must be SIGNED by the student-athlete
s parent, guardian or legal representative
regardless of the student-athlete
s age. The CSM Athletic Training Staff must have scanned the
student-athlete
s current health insurance card PRIOR to the student-athlete participating in
Colorado School of Mines Athletics practice and/or competition.
POLICY HOLDER INFORMATION
Policy Holder Last Name:
First Name:
Middle Initial:
Relationship to Student-Athlete:
INSURANCE INFORMATION
Name:
Type of Policy: HMO
Member ID#
Policy Limit (MUST be at least $2,000,000):
Does this policy cover injuries incurred during intercollegiate athletics participation? Yes
No
I,
as parent, guardian or legal representative, attest that
(student-athlete name)
has insurance coverage under a current, in force insurance policy for injuries that occur while he/she is participating in
intercollegiate athletics. This coverage has limits of at least $90,000.
If there is a material change in coverage or expiration of coverage, I agree to notify the Colorado School of Mines of this
development and update the insurance information I have on file with the Colorado School of Mines.
I understand and agree that the Colorado School of Mines will assume no responsibility whatsoever for the payment of, or
authorization to pay, medical expenses resulting in injuries that occur while participating in intercollegiate athletics at the
Colorado School of Mines.
I have read and agree to comply with the provisions of the Acknowledgement of Insurance Requirements.
Signed:
PARENT or GUARDIAN SIGNATURE REQUIRED
Date:
Parent, Guardian or Legal Representative
Signed:
Date:
Student-Athlete
The student-athlete must waive the CSM SHBP online thru his or her Trailhead account.
Colorado School of Mines Athletics
Sickle Cell Trait Testing & Waiver
2016-17
About Sickle Cell Trait
Sickle cell trait is an inherited condition of the oxygen-carrying protein, hemoglobin, in the red blood cells.
Sickle cell trait is a common condition (> three million Americans)
Although Sickle cell trait is most predominant in African-Americans and those of Mediterranean, Middle Eastern, Indian,
Caribbean, and South and Central American ancestry, persons of all races and ancestry may test positive.
An undiagnosed trait can be dangerous, even fatal. During intense, sustained exercise, hypoxia (lack of oxygen) in the
muscles may cause sickling of red blood cells (red blood cells changing from a normal disc shape to a crescent or
“sickle” shape), which can accumulate in the bloodstream and block blood vessels, leading to collapse from the rapid
breakdown of muscles starved of blood and possible death.
More information on sickle cell trait may be found at the following NCAA website: www.NCAA.org/health-safety
Sickle Cell Trait Testing
The NCAA mandates that all Division II student-athletes have knowledge of their sickle cell trait status before participating in athleticrelated activities including intercollegiate athletics events, strength and conditioning sessions, practices, competitions, etc.
INSERT YOUR NAME AND SELECT ONE OF THE THREE OPTIONS BELOW:
NAME:
CSM CWID:
SPORT:
1.
A copy of my sickle cell trait test from a physician or other authorized medical care provider is attached.
2.
I would like to be tested as part of my pre-participation physical examination. I understand that there may be a delay in my
medical clearance and that the results will be shared with the team physician.
3.
I voluntarily decline to be tested and understand that an undiagnosed trait can be dangerous, even fatal, and agree to sign the
waiver below. IF YOU CHOOSE THIS OPTION YOU MUST SIGN THE WAIVER BELOW.
SICKLE CELL TRAIT TESTING WAIVER AND RELEASE OF CLAIMS (ONLY COMPLETE IF OPTION 3 IS SELECTED ABOVE)
I,
(student-athlete name), understand and acknowledge that the NCAA and
Colorado School of Mines mandates all NCAA Division II student-athletes be tested for sickle cell trait, show proof of a prior test, or
sign a waiver releasing the school from liability if they decline to be tested before participating in athletic-related activities.
Recognizing that my true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms,
complaints, prior injuries, ailments, and/or other disabilities experienced. I hereby affirm that I have fully disclosed in writing any
knowledge of sickle cell trait status to the Colorado School of Mines Athletic Training staff.
I do not wish to undergo sickle cell testing as part of my pre-participation physical exam and I voluntarily agree to release,
discharge, indemnify and hold harmless Colorado School of Mines, their respective officers, coaches, associated medical staff,
instructors, agents or employees from any and all costs, liabilities, expenses, claims, demands, or causes of action on account of any
loss or personal injury that might result from my voluntary decision not to be tested.
I, the undersigned, have read this release and understand its terms. I execute it voluntarily and with full knowledge of its significance.
Signed: ___________________________________________________________
Parent / Guardian (Only if student is under 18)
Date: _____________________________
Signed: ___________________________________________________________
Student-Athlete
Date: _____________________________
May 2013