Student Athlete Health Forms by ngs20854

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									                           Student Athlete
                           Health Forms

Dear Marist Freshman/Transfer/Walk-On Athlete:

Welcome to Marist College!

Following this letter is a series of Student Athlete Health Forms that must be printed and completed by
you and your doctor. The Athletic Department requires that all student athletes undergo a pre-partici-
pation medical clearance process before any team practice or competition at Marist College. This must
include a physical exam by your physician before you come to campus. The examining physician must
record the results of your physical exam on this Physical Examination form; no other form will be ac-
cepted.

The forms must be completed in time to be received at Marist by July 15, or as soon as possible for late
admissions.

PLEASE MAKE TWO COPIES OF ALL FORMS. We advise that you keep a copy for your own records.
MAIL (do not fax) A SET OF COMPLETED FORMS TO EACH ADDRESS BELOW:
         1) Athletic Training Department            2) Office of Health Services
              McCann Center                            Student Center 350
              Marist College                           Marist College
              3399 North Road                          3399 North Road
              Poughkeepsie, NY 12601-1387              Poughkeepsie, NY 12601-1387

The forms request a copy of the front and back of your health insurance card. If you do not have family
health insurance, a letter stating this from your parent or guardian must be included with your medical
forms. If you will be under the age of 18 on the first day of practice, your parent or guardian must sign
your health history and consent forms.

While your family physician must fill out and sign your physical form, the Marist College Team Physi-
cian will have final pre-participation clearance authority for all student athletes. If you have
additional pertinent information (e.g. cardiology clearance for a heart murmur, or orthopedic surgeon
clearance after recent surgery), please include it in both packets. If you do not, the pre-participation
clearance process will be delayed.

If you are currently under a physician’s care for ADD/ADHD and take medications for this condition,
you must contact the Athletic Training Department for instructions on the documentation required by the
NCAA.

In addition, please note that all incoming athletes must attend a mandatory meeting on NCAA rules
and paperwork with the Marist College NCAA Compliance Officer.

With best wishes,

Glenn Marinelli                                           Mary L. Dunne, MD
Coordinator of Sports Medicine                            Director of Health Services

                                                                                                            1
                                                                                                                                    Marist
                                           Student Athlete                                                                 Sports Medicine
                                           Health Forms                                                                  Information Sheet


Sport:_____________________________________	                                                    Today’s	Date:___________________________
Name:________________________________________________________________________________________
          	          Last	   	         	         	         	         First	     	       	          	           	    Middle
	                                                                                                                          	 	                 	
Year:	    FR	        SO	     JR	       SR	       	         Cell	Phone#:___________________________Extension:	______________
Social	Security	#:	____________________________		 Age:__________	                                  DOB:	_____________________________
Home	Address:	Street	___________________________________________________________
	                City	_______________________________________________	 State	_____	Zip	Code	__________________
Mother’s	Name:	____________________________________	 Father’s	Name:________________________________
Home	Phone:	______________________________________	 Home	Phone:	_________________________________
Work	Phone:	______________________________________	 Work	Phone:	__________________________________
Cell	Phone:	_______________________________________	 Cell	Phone:	___________________________________
Additional	Parent	Address	(if	different	than	the	one	above,	please	indicate	which	parent	is	at	which	address):	         	 	             	
___________________________	 ____________	 ____________________	 _____________	 ___		___________
	 Name	                                         Phone	               Address	                          City	                   State	       Zip	Code

Emergency	Contact	Name	(non-Parent):___________________________________________________________________	
	                            	         	         First	    	         	          	       Last	      	           	    Relation

Home	Phone:	_______________________	Work	Phone:______________________	Cell	Phone:	______________________
Primary	Care	Physician:	________________________________________________
	         	          	       	         First	    	         	         	          Last

Office	Phone	Number:	_________________	Office	Fax	Number:	_________________
Insurance Information: 	This	must	be	completed,	there	will	be	NO	EXCEPTIONS!		If	you	do	not	have	insurance,	please	indicate	that	on	
the	top	line	and	attach	a	signed	letter	from	a	parent/guardian	stating	you	are	not	covered	by	any	insurance	carrier.		Also	a	copy	of	the	FRONT	AND	
BACK	must	be	attached	in	order	to	be	medically	cleared.
Name	of	Insurance	Company:__________________________________________________________________________
Address:	__________________________________City:	______________________________	State:	____	Zip:	________
Phone	Number:_______________________________	 Fax	Number:	_________________________
Plan/Group	Number:	________________________________	 Policy	Number:	___________________________________
Employee/Parent	Name:_______________________________________Employee	SSN/ID	#:	________________________	
Employer/Co	Name:	_______________________________________________________________________________


Please	Circle	Type:			       HMO	      	         PPO	      	         Other:	

                                                                                                                                                       2
         Work #                             Work #                         Work #

(_____)___________________      (_____)____________________       (______)__________________
          Cell #                   Health Cell #                            Cell #

_____________________________
          Email
                                   Sevices
                                __________________________
                                          Email




Name:_____________________________________________________________ Date _________________
              LAST                  FIRST                     MIDDLE


CWID#__________________________________________________ Date of Birth:____________________

        IF YOU HAVE COVERAGE OTHER THAN THE MARIST COLLEGE STUDENT ACCIDENT AND SICKNESS PLAN,
                   PLEASE COPY THE FRONT OF YOUR HEALTH INSURANCE CARD ON THIS PAGE
                     (OR INSERT ANOTHER PAGE WITH A COPY OF THE FRONT OF THAT CARD)




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                                Health
                                Sevices



Name:_____________________________________________________________ Date _________________
            LAST                  FIRST                 MIDDLE


CWID#__________________________________________________ Date of Birth:____________________

      IF YOU HAVE COVERAGE OTHER THAN THE MARIST COLLEGE STUDENT ACCIDENT AND SICKNESS PLAN,
                  PLEASE COPY THE BACK OF YOUR HEALTH INSURANCE CARD ON THIS PAGE
                    (OR INSERT ANOTHER PAGE WITH A COPY OF THE BACK OF THAT CARD)




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                                                                                                                                                                 Pre-participation
                                                      Student Athlete                                                                                                  Evaluation
                                                      Health Forms                                                                                                 HISTORY FORM

DATE OF EXAM__________________________________________

Name _________________________________________________                                                 Sex _____ Age ________ Date of birth __________________

Sport(s) ________________________________________________________________________________________________________

Address __________________________________________________________________ Phone ______________________________

Personal physician __________________________________________________________ Phone _______________________
In case of emergency, contact:
Name ________________________________ Relationship ______________ Phone (H) ______________ (W) ______________
     Explain	“Yes”	answers	below																																																																																		
     Circle	questions	you	don’t	know	the	answers	to.
	                                                                                                       Yes	 No 	                                                                                Yes	 No
1.	 Has	a	doctor	ever	denied	or	restricted	your	participation	in	sports	                                           23.	Has	a	doctor	ever	told	you	that	you	have	asthma	or	allergies?	            £	 £
   for	any	reason?	                                                                                      £	 £ 24.	Do	you	cough,	wheeze,	or	have	difficulty	breathing	during	or	after	exercise?	 £	 £
2.	 Do	you	have	ongoing	medical	condition	(like	diabetes	or	asthma)?	                                    £	£ 25.	Is	there	anyone	in	your	family	who	has	asthma?	                                 £	 £
3.	 Are	you	currently	taking	any	prescription	or	nonprescription	                                                  26.	Have	you	ever	used	an	inhaler	or	taken	asthma	medicine?	                  £	 £
   (over	the	counter)	medicines	or	pills?	                                                               £	£ 27.	Were	you	born	without	or	are	you	missing	a	kidney,	an	eye,	a	testicle,	
4.	 Do	you	have	allergies	to	medicines,	pollens,	foods,	or	stinging	insects?	 £	£ 	 or	any	other	organ?	                                                                                         £	 £
5.	 Have	you	ever	passed	out	or	nearly	passed	out	DURING	exercise?	                                      £	£ 28.	Have	you	had	infectious	mononucleosis	(mono)	within	the	last	month?	            £	 £
6.	 Have	you	ever	passed	out	or	nearly	passed	out	AFTER	exercise?	                                       £	£ 29.	Do	you	have	any	rashes,	pressure	sores,	or	other	skin	problems?	                £	 £
7.	 Have	you	ever	had	discomfort,	pain,	or	pressure	in	your	chest	during	                                          30.	Have	you	had	a	herpes	skin	infection?	                                    £	 £
   exercise?	                                                                                            £	£ 31.	Have	you	ever	had	a	head	injury	or	concussion?	                                 £	 £
8.	 Does	your	heart	race	or	skip	beats	during	exercise?	                                                 £	£ 32.	Have	you	been	hit	in	the	head	and	been	confused	or	lost	your	memory?	           £	 £
9.	 Has	a	doctor	ever	told	you	that	you	have	(check	all	that	apply):                                               33.	Have	you	ever	had	a	seizure?	                                             £	 £
   High	blood	pressure	£					A	heart	murmur	£                                                                      34.	Do	you	have	headaches	with	exercise?	                                     £	 £
   High	Cholesterol	£											A	heart	infection	£                                                                35.	Have	you	ever	had	numbness,	tingling,	or	weakness	in	your	arms	or	legs	
10.	Has	a	doctor	ever	ordered	a	test	for	your	heart?	(for	example,	                                                	 after	being	hit	or	falling?	                                                £	 £
   ECG,	echocardiogram)	                                                                                 £	£ 36.	Have	you	ever	been	unable	to	move	your	arms	or	legs	after	being	hit	or	falling?	£	 £
11.	Has	anyone	in	your	family	died	for	no	apparent	reason?	                                              £	£ 37.	When	exercising	in	the	heat,	do	you	have	severe	muscle	cramps	or	become	ill?	 £	 £
12.	Does	anyone	in	your	family	have	a	heart	problem?	                                                    £	£ 38.	Has	a	doctor	told	you	that	you	or	someone	in	your	family	has	sickle	cell	trait
13.	Has	any	family	member	or	relative	died	of	heart	problems	or	of                                                 	 or	sickle	cell	disease?	                                                    £	 £
   	sudden	death	before	age	50?	                                                                         £	£ 39.	Have	you	had	any	problems	with	your	eyes	or	vision?	                            £	 £
14.	Does	anyone	in	your	family	have	Marfan	syndrome?	                                                    £	£ 40.	Do	you	wear	glasses	or	contact	lenses?	                                         £	 £
15.	Have	you	ever	spent	the	night	in	a	hospital?	                                                        £	£ 41.	Do	you	wear	protective	eyewear,	such	as	goggles	or	a	face	shield?	              £	 £
16.	Have	you	ever	had	surgery?	                                                                          £	£ 42.	Are	you	happy	with	your	weight?	                                                £	 £
17.	Have	you	ever	had	an	injury,	like	a	sprain,	muscle	or	ligament	tear,	                                          43.	Are	you	trying	to	gain	or	lose	weight?	                                   £	 £
   or	tendinitis	that	caused	you	to	miss	a	practice	or	game?			                                          £	£ 44.	Has	anyone	recommended	you	change	your	weight	or	eating	habits?	                £	 £
   If	yes,	circle	affected	area	below:                                                                             45.	Do	you	limit	or	carefully	control	what	you	eat?	                          £	 £
18.	Have	you	had	any	broken	or	fractured	bones	or	dislocated	joints?	                                    £	£ 46.	Do	you	have	any	concerns	that	you	would	like	to	discuss	with	a	doctor?	         £	 £
   	If	yes,	circle	below:                                                                                          FEMALES	ONLY
19.	Have	you	had	a	bone	or	joint	injury	that	required	x-rays,	MRI,	CT,	                                            47.	Have	you	ever	had	a	menstrual	period?	                                    £	 £
   surgery,	injections,	rehabilitation,	physical	therapy,	a	brace,	a	cast,	                                        48.	How	old	were	you	when	you	had	your	first	menstrual	period?	               _______
   or	crutches?		If	yes,	check	below:	                                                                   £	£ 49.	How	many	periods	have	you	had	in	the	last	12	months?	                           _______
Head	£	Neck	£	Shoulder	£	Upper	Arm	£	Elbow	£	Forearm	£	Hand/fingers	£
Chest	£Upper	back	£	Lower	back	£	Hip	£	Thigh	£	Knee	£	Calf/shin	£                                  EXPLAIN	“Yes”	answers	here:	______________________________________
Ankle	£	Foot/toes	£
                                                                                                   _________________________________________________________
20.	Have	you	ever	had	a	stress	fracture?	                                             £	£
                                                                                                   _________________________________________________________
21.	Have	you	been	told	that	you	have	or	have	you	had	an	x-ray	for
   atlantoaxial	(neck)	instability?	                                                  £	 £         _________________________________________________________
22.	Do	you	regularly	use	a	brace	or	assistive	device?	                                £	 £         _________________________________________________________
                                                                                                   _________________________________________________________
                                                                                                   _________________________________________________________
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Signature	of	athlete	_______________________________	Signature	of	parent/guardian	_________________________	___	Date	
                                                                                                                                                                                                     5
                                                                                                                                                                     Pre-participation
                                                               Student Athlete                                                                                     Physical Evaluation
                                                               Health Forms                                                                             PHYSICAL EXAMINATION FORM

Name	_______________________________________________________		Date	of	birth_____________________________
Height	___________Weight	_________%Body	fat	(optional)	_______Pulse	______	BP		____/_______(____/____,____/____)
Vision					R	20/_____	L	20/	_____Corrected:			Y						N									Pupils:						Equal	______								Unequal	______
Questions on More Sensitive Issues                                                                                                                                                         Yes	 No
1.	 Do	you	feel	stressed	out	or	under	a	lot	of	pressure?	                                                                                                                                  £	 £
2.	 Do	you	ever	feel	so	sad	or	hopeless	that	you	stop	doing	some	of	your	usual	activities	for	more	than	a	few	days?	                                                                       £	 £
3.	 Do	you	feel	safe?	                                                                                                                                                                     £	 £
4.	 Have	you	ever	tired	cigarette	smoking,	even	1	or	2	puffs?	Do	you	currently	smoke?	__________	                                                                                          £	 £
5.	 During	the	past	30	days,	did	you	use	chewing	tobacco,	snuff,	or	dip?	                                                                                                                  £	 £
6.	 During	the	past	30	days,	have	you	had	at	least	1	drink	of	alcohol?	                                                                                                                    £	 £
7.	 Have	you	ever	taken	steroid	pills	or	shots	without	a	doctor’s	prescription?	                                                                                                           £	 £
8.	 Have	you	ever	taken	any	supplements	to	help	you	gain	or	lose	weight	or	improve	your	performance?	                                                                                      £	 £


Notes:_________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
	  	                                           Normal	                                                 Abnormal	Findings	                                                 Initials*
       Notes:                                            NORMAL                                        ABNORMAL FINDINGS                                                       INITIALS 
       MEDICAL                                                      
                                                                                                                                                                 
       Appearance                                                   
       Eyes/ears/nose/throat                                             
       Hearing                                                           
       Lymph nodes                                                       
       Heart                                                             
       Murmurs                                                           
       Pulse                                                             
       Lungs                                                             
       Abdomen                                                           
                                +
       Genitourinary (males only)                                        
       Skin                                                              
                                                                         
       MUSCULOSKELETAL 
       Neck                                                              
       Back                                                              
       Shoulder/arm                                                      
       Elbow/forearm                                                     
       Wrist/hand/fingers                                                
       Hip/thigh                                                         
       Knee                                                              
       Leg/ankle                                                         
       Foot/toes                                                         
                                                                  
    *Multiple	examiner	set	up	only
      Multiple examiner set up only 
    +Having	a	third	party	present	is	recommended	for	the	genitourinary	examination.
       Having a third party present is recommended for the genitourinary examination. 
    Notes:___________________________________________________________________________________________
      
    _______________________________________________________________________________________________
     Notes: 
      
    Name	of	physician	(print/type)		_______________________________________________________Date	_________________
     Name of physician (print/type)                                                                                                                       Date 
    Address	______________________________________________________________	Phone	_______________________
      
    Signature	of	physician	_________________________________________________	MD	or	DO	
     Address                                                                                                                               Phone 
                                                                                                                                                                                                     6
       Signature of physician                                                                                                                                           MD or DO 
                                                                                                                     Pre-participation
                                         Student Athlete                                                           Physical Evaluation
                                         Health Forms                                                               CLEARANCE FORM


Athlete’s	Name	_________________________________________		Sex	_____	Age	_______Date	of	birth_______________
£        Cleared	without	restriction
£        Cleared,	with	recommendations	for	further	evaluation	or	treatment	for:__________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________


£	Not	cleared	for: £ All	sports	£	Certain	sports:_______________________ Reason:_____________________________
Recommendations:	________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________


EMERGENCY	INFORMATION
Allergies	______________________________________________________________________________________
Other	Information	________________________________________________________________________________
IMMUNIZATIONS	(e.g.,	tetanus	/diphtheria;	measles,	mumps,	rubella;	hepatitis	A,	B;	influenza;	poliomyelitis;	pneumococcal;	meningococcal;	vari-
cella)
£	Up	to	date	(attach	documentation)			
£	Not	up	to	date				Specify	_____________________________________________
Name	of	physician	(print/type)	________________________________________________________	
Address	______________________________________	City	_______________________	ST______		Zip	____________
Phone	______________________________________
Signature	of	physician	_________________________________________________,		MD	or	DO		 Date	_________________




                                                                                                                                                  7
                                                                                                                                             4
                                                      Health
                                                      Sevices



 Name___________________________________________________________ Date __________________
                        LAST                             FIRST                                MIDDLE


 CWID#__________________________________________________ Date of Birth:____________________

 Home Address: ____________________________________________________________________________________
                               (STREET                                               (CITY)                    (STATE)         (ZIP CODE)

 Student cell phone:______________________________                            Email address:______________________________________

                                     MARIST COLLEGE MANDATORY IMMUNIZATION INFORMATION


 N.Y.S. Public Health Law § 2165 requires post-secondary students to show protection against measles, mumps and rubella.
 Persons born prior to January 1, 1957, are exempt from this requirement. Immunizations below must have been given after 1957 AND
 after the first birthday; the second immunization must have been given at or after 15 months of age.

 HEALTH CARE PROVIDER TO COMPLETE

 The following section must be completed and signed by a licensed health care provider unless the student is
 providing a copy of a high school health record or a certified vaccine record (please attach). Dates must include
 month, day, and year.

                Immunization                                                                    Date (month/day/year)

                                                Administered after first birthday
 1. Measles – First dose
                                              Administered after 15 months of age,
 2. Measles – Second Dose                       at least 30 days after first dose
                                                Administered after first birthday
 3. Mumps
                                                 One live vaccine administered
 4. Rubella                                            after first birthday

                                                           OR


 1. MMR #1 (measles, mumps,rubella)             Administered after first birthday


 2. MMR #2


                                                           OR

                                                 Blood test proving immunity to
 Titer                                           Measles, Mumps, and Rubella


 HIGHLY RECOMMENDED VACCINES AND TESTING:

 - Hepatitis B                               Date #1:_________ Date #2:_________ Date #3 :_________
 - Meningococcal vaccine                     Date____________ (see attached letter about NYS law)
 - Tetanus booster                           Date: ____________ Tt or Td or Tdap (circle)
 - Varicella/Chicken Pox                     MD Diagnosed _______ Titer Results ________ Vaccine______________
                                              st                                            rd
 - HPV Vaccine (Gardasil)                    1 Dose___________ 2nd Dose___________ 3 Dose______________                                      5

____________________________________                   ____________________________________________                      _________________
         Print name of Health Practitioner                                   Signature                                        Date



                                                                                                                                                 8
                                                       Health
                                                       Sevices
                                                                                                                                                                 2


Name____________________________________________________ Date _________________________
              LAST                                FIRST                        MIDDLE

CWID#__________________________________________________ Date of Birth:___________________

                                MEASLES, MUMPS, AND RUBELLA (MMR) VACCINATION INFORMATION

New York State Public Health Law 2165 requires undergraduate, graduate, and professional students to demonstrate acceptable
proof of immunity against measles, mumps and rubella to the schools in which they are enrolling. The law applies only to students born
on or after January 1, 1957.

Entering students are required to submit proof of immunization or documentation of medical or religious exemption. Your
Immunization information must be received by Marist Health Services by August 3 for the Fall Semester.

Marist College is mandated by New York State law to enforce this requirement. As part of the compliance procedure, Marist College
submits an annual report to the New York State Department of Health attesting to the status of our students’ immunizations. Marist
College is also subject to audits by the State.

Note: Fines resulting from any such audit conducted by the State that arise from an individual student’s failure to comply with
this law will be passed on to that student.

Required Vaccinations
One of the following is required:
         Two measles vaccines, one mumps vaccination and one rubella vaccination

         Two measles, mumps, rubella vaccinations (MMR1 and MMR2)

         A blood test showing immunity to measles, mumps and rubella

Acceptable Proof of MMR Immunization

You may submit any one of the following as proof of MMR immunization:

         The Marist College Mandatory Immunization Information Form (page 3) completed and signed by your health care provider

                                                      OR

         A copy of your health care provider-certified immunization record

                                                      OR

         An immunization record from your high school or another college or the armed services. (Proof of honorable discharge from the armed services
          within 10 years of enrollment in Marist College will allow you to attend classes pending actual receipt of your immunization records.)

Exceptions
Proof of MMR immunization is not necessary if any of the following exceptions apply:
         If you are a student born before January 1, 1957

         If you are unable to receive a vaccine for medical reasons and your doctor writes a note to this effect and signs it

         If you are unable to receive a vaccine for religious reasons and you submit documentation. In the event of an outbreak of measles, mumps or
          rubella, you will not be allowed to attend class

If immunization is needed: Dutchess County Health Department 387 Main Street, Poughkeepsie, NY 12601 845-486-3401

----------------------------------------------------------------------------------------------------------------------------------------------------- --------
I have read, or have had explained to me, the information regarding NYS MMR requirements.



Student Signature                          ____________________________________________ ________________
                                           (Parent must sign if student is younger than 18 years of age.) (relationship)
                                                                                                                                                                     9
                                            Health
                                            Sevices                                                                              3




Name___________________________________________________________ Date __________________
                LAST                         FIRST                 MIDDLE


CWID#__________________________________________________ Date of Birth:____________________

                                        MANDATORY MENINGITIS INFORMATION


New York State Public Health Law §2167 requires that colleges and universities distribute information about
meningococcal disease and vaccinations to all students.

Meningitis is rare. However, when it strikes, its flu-like symptoms make diagnosis difficult. If not treated early, meningitis
can lead to swelling of the fluid surrounding the brain and spinal column, as well as severe and permanent disabilities,
such as hearing loss, brain damage, seizures, limb amputation, and even death.

Cases of meningitis among teens and young adults 15 to 24 years of age have doubled since 1991. The disease strikes
about 3000 Americans each year and claims about 300 lives. Between 100 and 125 meningitis cases occur on college
campuses and as many as 15 students will die from the disease.

A vaccine is available that protects against four types of the bacteria that cause meningitis in the United States (types A, C,
Y and W-135); these types cause nearly two-thirds of the meningitis cases among college students.

It is mandatory that you consider this information, complete the form below and return it to Marist Health Services.


                             MANDATORY MENINGITIS VACCINATION RESPONSE FORM


New York State Public Health Law §2167 mandates that all college and university students enrolled for at least six (6)
semester hours or the equivalent per semester, or at least four (4) semester hours per quarter, complete the following
form.


I have/my child has:        (check one box and sign below)

‫ڤ‬    had the meningococcal meningitis immunization within the past 10 years

           Menomune:        date received    ____________

                or

           Menactra:        date received    ____________

‫ڤ‬    read, or have had explained to me, the information regarding meningococcal disease. I understand the risks of not
receiving the vaccine.




Student signature                _________________________________________________

                                 (Parent must sign if student is younger than 18 years of age.)




                                                                                                                                     10
                                            Health
                                            Sevices



Name___________________________________________________________ Date __________________
                 LAST                        FIRST                        MIDDLE


CWID#__________________________________________________ Date of Birth:____________________

                                        MEDICAL AUTHORIZATION AND CONSENT

FOR STUDENT 18 OR OVER WHEN STARTING SCHOOL:

I hereby consent to treatment by Marist College Health Services staff. In the event of an emergency, I consent to
treatment by the Saint Francis Hospital Emergency Department staff.

I agree to allow Saint Francis Hospital to provide Marist College Health Service with information concerning any medical
treatments I may require during the Marist College academic year. I understand that this information is necessary for
appropriate follow-up care by Marist Health Services or the private physicians to whom I may be referred.

__________________________________________                                      ________________
         Student signature                                                           Date


FOR PARENTS OF STUDENTS WHO WILL BE UNDER 18 YEARS OF AGE WHEN STARTING SCHOOL:

STUDENTS UNDER 18 YEARS OLD CANNOT RECEIVE TREATMENT WITHOUT PARENTAL CONSENT.

I hereby consent for Marist College Health Services, Saint Francis Hospital, or a medical professional designated by either,
to treat

                                   ____________________________________________
                                             (Student’s name - Please Print)

in the event that I cannot be contacted, or in the judgment of medical professionals, immediate attention is required prior to
my being contacted.
                                                                                                                               10
I agree to allow Saint Francis Hospital to provide Marist College Health Services with information concerning any
medical treatments the above may require during the Marist College academic year. I understand that this information is
necessary for appropriate follow-up care by Marist Health Services or the private physicians to whom the above may be
referred.


_______________________________                      _________________________________                 ____________
     Parent/Guardian Signature                           Print Parent/Guardian Name                       Date

____________________________
   Relationship to student



PARENTS, PLEASE NOTE:

Parental notification of treatment for illness or injury of any student over 18 years of age is the responsibility of the student.
Marist College staff will actively encourage students to inform their parents/guardians of illness, injury, or medical
treatment.




                                                                                                                                     11
                                  Health
                                  SevicesMARIST



CONSENT TO DISCUSS MEDICAL CONDITION FOR STUDENTS 18 AND OLDER




I hereby give my consent to Marist College Health Services to discuss my medical condition with my
parent(s) or guardian(s), listed below. I understand that I can withdraw this permission at any time.


PARENT(S) OR GUARDIAN(S)



________________________________________________________________
       Name                             Relationship



________________________________________________________________
       Name                             Relationship


STUDENT



________________________________________________________________
       Name of student                  Date of birth




________________________________________________________________
       Signature                        Date




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                                                                                                 Student-Athlete
                                                                           Authorization/Consent for Disclosure
                              Student Athlete                                 of Protected Health Information to
                              Health Forms                           the National Collegiate Athletic Association




I ______________________________________ hereby authorize __________________________________
             Name of Student-Athlete                                   Name of my Institution

and its physicians, athletic trainers and health care personnel to disclose my protected health information and
any related information regarding any injury or illness during my training for and participation in intercolle-
giate athletics to the National Collegiate Athletic Association (NCAA) and its employees or agents.

I understand that my protected health information will he used only by the NCAA’s Injury Surveillance System
(ISS) for the purpose of conducting research on injuries resulting from training for or participation in athletics.
The ISS is a longitudinal research database that provides the NCAA, NCAA sports rules committees, athletic
conferences, researchers and individual schools with summary (aggregate) injury and participation informa-
tion that does not identify individual athletes or schools. The summary data provide the Association and other
groups with an information resource upon which to base health and safety rules and policy and to examine
the effectiveness of such efforts.

I understand that my injury/illness information is protected by federal regulations under either the Health In-
formation Portability and Accountability Act (HIPAA) or the Family Educational Rights and Privacy Act of 1974
(the Buckley Amendment) and may not be disclosed without either my authorization under HIPAA or my con-
sent under the Buckley Amendment

I understand that my signing of this authorization/consent is voluntary and that my institution will not condi-
tion or withhold any health care treatment or payment, enrollment in a health plan or receipt of any benefits
(if applicable) on whether I provide the consent or authorization requested for this disclosure. I also under-
stand that I am not required to sign this authorization/consent in order to be eligible for participation in NCAA
athletics.

I understand that while HIPAA regulations do not apply to the NCAA’s use or disclosure of my injury/illness
information, the NCAA is committed to protecting my privacy. I understand that the protected health informa-
tion will be encoded before being transmitted from my institution to the NCAA and that neither the NCAA nor
the ISS will identify me personally in any publication or disclosure of research results. Data will be stored on
a secure server at the NCAA national office in Indianapolis, Indiana.

This authorization/consent expires 380 days from the date of my signature below, but I have the right to re-
voke it in writing at any time by sending written notification to the athletics director at my institution. I under-
stand that a revocation takes effect on its request date and does not affect any action taken prior to that date.

Printed Name of Student-Athlete _________________________________________________

Signature ____________________________________________________ Date_________________________




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