Athlete Name

Document Sample
Athlete Name Powered By Docstoc
					Athlete Name: __________________________________________________

Sport: Cheerleading     Squad: __________________________________




                        Stephen F. Austin
                         State University


                      New / Incoming Athlete




                           Due: June 1, 2011




                                                                    Page 1 of 19
                               STEPHEN F. AUSTIN STATE UNIVERSITY
                                            ATHLETE
                                     CONTACT INFORMATION

Last Name: _________________________________________ First Name: ______________________________________


Middle Name: _______________________________________ Nickname: _______________________________________


SS#: ________ - ______ - __________ Campus ID # _____________________ Sport: Cheerleading


Birth Date: ______ / ______ / __________      Age: ______   Sex: _____   Marital Status: S / M / D


       Preferred Email Address:_______________________________________@___________________________________


Current SFA Classification:   ______ Incoming Freshman      ______ Sophomore


                              ______ Junior          ______ Senior       ______ Graduate Student




Local / Campus Address: _________________________________________        Phone: (________) _________ - __________


City: Nacogdoches     State: Texas    Zip: 7596___                       Cell Phone: (_______) ________ - _________


Father / Guardian: _____________________________________________         Work Phone: (_______) _______ - _________


Home Address: ________________________________________________           Home Phone: (_______) _______ - _________


City: _________________________ State: __________ Zip: ____________      Cell Phone: (_______) _______ - __________


Mother / Guardian: ____________________________________________          Work Phone: (_______) ______ - __________


Home Address: ________________________________________________           Home Phone: (______) _______ - __________


City: _________________________ State: __________ Zip:_____________      Cell Phone: (_______) _______ - __________


Contact Person in Case of an Emergency (Non-Relative):                   Home Phone: (_______) _______ - _________


Name: ______________________ Relationship: ____________________          Cell Phone: (_______) _______ - __________


Family Physician: ______________________________________________         Phone: (________) _________ - ___________



                                               '11 - '12 Academic Year

                                                                                                       Page 2 of 19
                   Stephen F. Austin State University – Insurance Information Questionnaire

Athlete’s Name_____________________________________________________________________ Sport CHEERLEADING

Social Security Number (Athlete) ______________-______________-______________________________

                                                   Parent/Guardian Information

Father/Guardian Name ________________________________              Mother/Guardian Name _______________________________

Address ___________________________________________                Address ___________________________________________

___________________________________________________                ___________________________________________________

Telephone __________________________________________               Telephone __________________________________________

Email ______________________________________________               Email ______________________________________________

                    Is Father employed? Yes / No                                     Is Mother employed? Yes / No

Employer __________________________________________                Employer __________________________________________

Emp. Address _______________________________________               Emp. Address _______________________________________

___________________________________________________                ___________________________________________________

Emp. Telephone _____________________________________               Emp. Telephone _____________________________________


                     Is Father insured? Yes / No                                      Is Mother insured? Yes / No

If “No”, please sign here:                                         If “No”, please sign here:

___________________________________________________                ___________________________________________________

Insurance Company Plan ______________________________              Insurance Company Plan ______________________________

Policy Number ______________________________________               Policy Number ______________________________________

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

      ______________________________________________                   ______________________________________________
                 Signature of Insured (Parent)                                    Signature of Insured (Parent)

                   __________________________                                        __________________________
                              Date                                                              Date

          ________________________________________                         ________________________________________
             Social Security Number of Insured (Parent)                       Social Security Number of Insured (Parent)

                   __________________________                                        __________________________
                    Birth Date of Insured (Parent)                                    Birth Date of Insured (Parent)

My insurance company requires special forms to                     My insurance company requires special forms to
be filled out: Yes _____ No _____                                  be filled out: Yes _____ No _____

                 If yes, please attach signed forms.                              If yes, please attach signed forms.



            * Please attach a copy of the front and back of your insurance card (s) *
                                                       '11 - '12 Academic Year
                                                                                                                        Page 3 of 19
                                  Student-Athlete Authorization/Consent
                                                      for
                                 Disclosure of Protected Health Information
                                                    to the
                                  National Collegiate Athletic Association



                                                           STEPHEN F. AUSTIN STATE UNIVERSITY
I, ____________________________ hereby authorize _______________________________
Name of Student-Athlete                          Name of my Institution

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

        I understand that my protected health information will be 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 maintained by the NCAA that provides NCAA sports rules
committees, athletic conferences, researchers and individual schools with summary (aggregate) injury and
participation information 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
Information 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 consent
under the Buckley Amendment. I understand that my signing of this authorization/consent is voluntary and that my
institution will not condition 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 understand 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 may 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
information and any personal identifiers will be encrypted while being transmitted from my institution to the NCAA
and that all data will be stored on a secure server at the NCAA national office in Indianapolis, Indiana. I further
understand that neither the NCAA nor the ISS will identify me personally in any publication or disclosure of
research results.

        This authorization/consent expires 545 days from the date of my signature below, but I have the right to
revoke it in writing at any time by sending written notification to the athletics director at my institution. I
understand that a revocation takes effect on its request date and does not affect any action taken prior to that date.



____________________________________                     _______________________________________________
Printed Name of Student-Athlete                          Signature                             Date



                                          '11 - '12 Academic Year



                                                                                                           Page 4 of 19
                              Form 06-3d Academic                                                   Year 2011-12



                             Drug-Testing Consent − Division I
                             For:                    Student-athletes.
                             Action:                 Sign and return to your director of athletics.
                             Due date:               At the time your intercollegiate squad first reports for practice
                                                     or the Monday of the institution’s fourth week of classes,
                                                     whichever date occurs first.
                             Required by:            NCAA Constitution 3.2.4.6 and NCAA Bylaws 14.1.4 and 30.5.
                             Purpose:                To assist in certifying eligibility.



TO: STUDENT-ATHLETE
                                    STEPHEN F. AUSTIN STATE UNIVERSITY
Name of your institution: _________________________________________________________


You must sign this form to participate (i.e., practice or compete) in intercollegiate athletics. Per
NCAA Bylaw 30.5-(b), the director of athletics or the director of athletics’ designee shall disseminate a copy of the list
of banned drug classes (Attachment) to all student-athletes and educate them about products that might contain banned
drugs. Please note that the list may change during the academic year, that updates may be found on the NCAA Web
site (www.ncaa.org), and you will be informed of the procedures your athletics department will use to disseminate
updates to the list.


NCAA Constitution 3.2.4.6 and Bylaws 14.1.4 and 30.5 require that you sign this form. If you have any questions, you
should discuss them with your director of athletics.



Drug-Testing Consent


By signing this form, you affirm that you are aware of the NCAA drug-testing program, which provides:


A student-athlete who is found to have used a substance on the list of banned drugs, as set forth in Bylaw 31.2.3.1,
shall be declared ineligible for further participation in regular season and postseason competition in all sports in
accordance with the provisions in Bylaw 18.4.1.5.1. The certifying institution may appeal to the NCAA Student-
Athlete Reinstatement Committee for restoration of the student-athlete's eligibility if the institution concludes that
circumstances warrant restoration. (Bylaw 18.4.1.5)


A student-athlete who tests positive (in accordance with the testing methods authorized by the NCAA Executive
Committee) shall be ineligible to participate in regular-season and postseason competition for one calendar year (i.e.,
365 days) after the positive drug test and shall be charged with the loss of a minimum of one season of competition in
all sports. The student-athlete shall remain ineligible for all regular-season and postseason competition for one
calendar year after the student-athlete's positive drug test, and until the student-athlete retests negative (in

                                               '11 - '12 Academic Year
                                                                                                             Page 5 of 19
Drug-Testing Consent − Division I
Form 06-3d
Page No. 2
_________



accordance with the testing methods authorized by the Executive Committee) and the student athlete's eligibility is
restored by the Student-Athlete Reinstatement Committee. If a student athlete transfers to another NCAA institution
while ineligible due to a positive NCAA drug test, the institution from which the student-athlete transfers must notify
the transfer institution regarding the positive drug test result.


If the student-athlete tests positive a second time for the use of any drug, other than a "street drug" as defined in Bylaw
31.2.3.1, he or she shall lose all remaining regular-season and postseason eligibility in all sports. A combination of
two positive tests involving street drugs (e.g., marijuana, heroin) in whatever order, will result in the loss of an
additional year of eligibility (Bylaw 18.4.1.5.1). In addition, the penalty for missing a scheduled drug test is the same
as the penalty for testing positive for the use of a banned drug other than a street drug.


If the student-athlete tests positive for the use of a "street drug" after being restored to eligibility, he or she shall be
charged with the loss of a minimum of one additional season of competition in all sports and also shall remain
ineligible for regular-season and postseason competition at least through the next calendar year. If the student-athlete
transfers to another NCAA institution while ineligible, the institution from which the student-athlete transferred must
notify the institution that the student-athlete is ineligible due to a positive drug test result. If the student athlete
immediately transfers to a non-NCAA institution while ineligible and competes in collegiate competition within the
365-day period at a non-NCAA institution, the student-athlete will be ineligible for all NCAA regular-season and
postseason competition until the student athlete does not compete in collegiate competition for a 365-day period.
Additionally, the student-athlete must retest negative (in accordance with the testing methods authorized by the
Executive Committee) and request that eligibility be restored by the NCAA Division I
Academic/Eligibility/Compliance Cabinet. (Bylaw 18.4.1.5.1)


The Executive Committee shall adopt a list of banned drug classes and shall authorize methods for drug testing of
student-athletes on a year-round basis. This list of banned drug classes and the procedure for informing member
institutions about authorized methods for drug testing are set forth in Bylaws 31.2.3.1 and 31.2.3.3 respectively. The
list is subject to change and the institution and student-athlete shall be held accountable for all banned drug classes on
the current list (Attachment). The list is located on the NCAA Web site (www.ncaa.org) or may be obtained from the
NCAA health and safety staff in Education Outreach. (Bylaw 18.4.1.5.2)

You agree to allow the NCAA to test you in relation to any participation by you in any NCAA championship or in any
postseason football game certified by the NCAA for the banned drugs listed in Bylaw 31.2.3.1. Additionally, if you
participate in a Division I NCAA sport, you also agree to be tested on a year-round basis for anabolic agents, diuretics,
ephedrine and urine manipulators and peptide hormones.




                                                „11 - '12 Academic Year



                                                                                                                Page 6 of 19
Drug-Testing Consent – Division I
Form 06-3d
Page No. 3
_________



You agree to allow your drug-test sample to be used by the NCAA drug-testing laboratories for research purposes to
improve drug-testing detection. Individual samples will not be personally identified.

You were provided an opportunity to review the procedures for NCAA drug testing that are described in the NCAA
Drug-Testing Program brochure.

You understand that this consent and the results of your drug tests, if any, only will be disclosed in accordance with
the provisions of the Buckley Amendment consent.

You agree to disclose your drug-testing results only for purposes related to your eligibility for participation in regular-
season and postseason competition.

You affirm that you understand that if you sign this statement falsely or erroneously, you violate
NCAA legislation on ethical conduct, and you will further jeopardize your eligibility.


_______________________                       ___________________________________________________
Date                                          Signature of student-athlete

_______________________                       ___________________________________________________
Date                                          Signature of parent (if student-athlete is a minor)

_________________________________________                     __________________             _________
Name (please print)                                           Date of birth                  Age

__________________________________________________________________________________
Home address

CHEERLEADING
Sport(s)




What to do with this form: Sign and return it to your director of athletics at the time your intercollegiate squad first
reports for practice or the Monday of the institution's fourth week of classes (whichever date occurs first). This form is
to be kept in the director of athletics office for six years.



The National Collegiate Athletic Association
February 1, 2006

                                                '11 - '12 Academic Year



                                                                                                              Page 7 of 19
    NCAA Banned-Drug Classes
    2008-2009                                                                                                        ATTACHMENT
    The NCAA list of banned-drug classes is subject to change by the                  methandienone                 other anabolic agents
NCAA Executive Committee. Contact NCAA education services or                          methenolone                   clenbuterol
www.ncaa.org/health-safety for the current list. The term “related
compounds” comprises substances that are included in the class by their
pharmacological action and/or chemical structure. No substance
belonging to the prohibited class may be used, regardless of                    (c) Substances Banned for Specific Sports:
whether it is specifically listed as an example.                                Rifle:
    Many nutritional/dietary supplements contain NCAA banned                           alcohol                  pindolol
substances. In addition, the U.S. Food and Drug Administration (FDA)                   atenolol                 propranolol
does not strictly regulate the supplement industry; therefore purity and               metoprolol               timolol
safety of nutritional dietary supplements cannot be guaranteed. Impure                 nadolol                  and related compounds
supplements may lead to a positive NCAA drug test. The use of
supplements is at the student-athlete’s own risk. Student-athletes should       (d) Diuretics:
contact their institution’s team physician or athletic trainer for further            acetazolamide                 hydrochlorothiazide
information.                                                                          bendroflumethiazide           hydroflumethiazide
    Bylaw 31.2.3. Banned Drugs                                                        benzhiazide                   methyclothiazide
    The following is a list of banned-drug classes, with examples of                  bumetanide                    metolazone
substances under each class:                                                          chlorothiazide                 polythiazide
(a) Stimulants:                                                                       chlorthalidone                quinethazone
       amiphenazole                    methylenedioxymethamphetamine                  ethacrynic acid               spironolactone
       amphetamine                            (MDMA, ecstasy)                         flumethiazide                 triamterene
       bemigride                       nikethamide                                    furosemide                    trichlormethiazide
       benzphetamine                   pemoline                                                                     and related compounds
       bromantan                       pentetrazol
       caffeine1 (guarana)             phendimetrazine                          (e) Street Drugs:
       chlorphentermine                phenmetrazine                                  heroin                        tetrahydrocannabinol
       cocaine                         phentermine                                    marijuana3                         (THC)3
       cropropamide                    phenylephrine
       crothetamide                    phenylpropanolamine (ppa)                (f) Peptide Hormones and Analogues :
       diethylpropion                  picrotoxine                                    corticotrophin (ACTH)
       dimethylamphetamine             pipradol                                       human chorionic gonadotrophin (hCG)
       doxapram                        prolintane                                     leutenizing hormone (LH)
       ephedrine                       strychnine                                     growth hormone(HGH, somatotrophin)
          (ephedra, ma huang)          synephrine                                     insulin like growth hormone (IGF-1)
       ethamivan                           (citrus aurantium, zhi shi, bitter
       ethylamphetamine                     fencamfamine orange)                All the respective releasing factors of the above-mentioned
       methamphetamine                 and related compounds                    substances also are banned:
       meclofenoxate                                                                  erythropoietin (EPO)         sermorelin
                                                                                      darbypoetin
(b) Anabolic Agents:
      anabolic steroids                                                         (g) Definitions of positive depends on the following:
      androstenediol                  methyltestosterone                              1for caffeine—if the concentration in urine exceeds 15 micrograms/ml.
      androstenedione                 nandrolone                                      2for testosterone—if the administration of testosterone or use of any
      boldenone                       norandrostenediol                               other manipulation has the result of increasing the ratio of the total
      clostebol                       norandrostenedione                              concentration of testosterone to that of epitestosterone in the urine
      dehydrochlormethyl-             norethandrolone                                 to greater than 6:1, unless there is evidence that this ratio is due to
          testosterone                oxandrolone                                     a physiological or pathological condition.
      dehydroepiandro-                oxymesterone                                    3for marijuana and THC—if the concentration in the urine of THC
          sterone (DHEA)               oxymetholone                                   metabolite exceeds 15 nanograms/ml. of any other manipulation has
      dihydrotestosterone             stanozolol                                      the result of increasing the ratio of the total concentration of
          (DHT)                       testosterone2                                   testosterone to that of epitestosterone in the urine to greater than
      dromostanolone                  tetrahydrogestrinone (THG)                      6:1, unless there is evidence that this ratio is due to a physiological
      epitrenbolone                   trenbolone                                      or pathological condition.
      fluoxymesterone                 and related compounds
      gestrinone
      mesterolone


                                                                    '11 - '12 Academic Year


                                                                                                                                                     Page 8 of 19
                                                             MEDICAL CONSENT - Part
I hereby grant permission to the Stephen F. Austin State University team physicians
and /or their consulting physician to render to my son or daughter or myself, any treatment
or medical or surgical care that they deem reasonably necessary to the health and well-being
of the athlete.

I also hereby authorize the athletic trainers at Stephen F. Austin State University who are
under the direction and guidance of the Stephen F. Austin State University team physicians,
to render to my son or daughter or myself, any preventative, first-aid, rehabilitative, or
emergency treatment that they deem reasonably necessary to the health and well-being
of the athlete.

Also, when necessary for executing such case, I grant permission for hospitalization at
an accredited hospital.


DATE: ____________________                       ______________________________________
                                                 SIGNATURE

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

                                                 ______________________________________
                                                 SOCIAL SECURITY NUMBER

                                                 ______________________________________
                                                 PARENT OR GUARDIAN




AUTHORIZATION FOR RELEASE OF INFORMATION - Part II

This is to authorize the Stephen F. Austin State University athletic trainers, team physicians,
and athletic coaches to release medical information on my son or daughter, or myself, to the
Stephen F. Austin State University Sports Information Department, and the various media
outlets, any information concerning illness or injury relative to my past, present, or future
participation in athletics at Stephen F. Austin State University.

DATE: ____________________                       ______________________________________
                                                 SIGNATURE

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

                                                 ______________________________________
                                                 SOCIAL SECURITY NUMBER

                                                 ______________________________________
                                                 PARENT OR GUARDIAN




                                           '11 - '12 Academic Year

                                                                                            Page 9 of 19
AUTHORIZATION FOR RELEASE OF INFORMATION - Part III

I, __________________________________________, hereby authorize and request Stephen F.
Austin State University, the Board of Regents, the Stephen F. Austin Athletic Department and their duly
authorized agents, servants, or employees (including coaches, trainers, and physicians) to furnish to all
professional athletic teams, their scouts, representative agents, trainers, physicians, servants, or employees,
any and all information concerning or having bearing upon my participation in athletics at Stephen F. Austin
State University. Said authorization shall include, but is not limited to any and all information within their knowledge,
or contained in any records under their supervision or control concerning my physical condition, illnesses, injuries,
and any treatment, hospitalization, examinations, X-rays, and otherwise, and to make such reports to such persons
or organizations concerning myself as they may request; and I hereby fully discharge all parties to whom this
authorization extends from any and all privilege in connection with the disclosure of information included in this
authorization.


DATE: ____________________                         ______________________________________
                                                   SIGNATURE

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

                                                   ______________________________________
                                                   SOCIAL SECURITY NUMBER

                                                   ______________________________________
                                                   PARENT OR GUARDIAN



SHARED RESPONSIBILITY FOR SPORTS SAFETY - Part IV
Participation in sport requires an acceptance of risk or injury. Athletes rightfully assume that those who are
responsible for the conduct of sport have taken reasonable precaution to minimize such risk and that their
peers participating in the sport will not intentionally inflict injury upon them.

Periodic analysis of injury patterns, refinements in rules, and other safety decisions are being made. However,
to legislate safety via a rule book and equipment standards, while often necessary, seldom is effective by itself;
and to rely on officials to enforce compliance with the rule book is as insufficient as to rely on warning labels to
produce compliance with safety guidelines. "Compliance" means respect on everyone's part for the intent and
purpose of a rule or guideline.

I have read the above shared responsibility statement. I understand that there are certain inherent risks
involved in participating in intercollegiate athletics. I acknowledge the fact that these risks exist and I am
willing to assume responsibility for such risks while participating at Stephen F. Austin State University.


DATE: ____________________                         ______________________________________
                                                   SIGNATURE

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

                                                   ______________________________________
                                                   SOCIAL SECURITY NUMBER

                                                   ______________________________________
                                                   PARENT OR GUARDIAN




                                            '11 - '12 Academic Year
                                                                                                                 Page 10 of 19
Please be reminded of the medical policy of No Visible Jewelry for all practices and
events. Visible jewelry is defined as any items that are readily visible in your normal
practice or game uniform. If your typical practice attire does not include a shirt and you
have a belly button ring, it must be removed. Items that are always visible and therefore
must be removed are earrings, necklaces, watches, fingers rings, brow rings, belly
button rings, nose rings, and tongue piercing.
This policy is for the safety you, the athlete, and for the safety of your teammates.

Five typical injuries can happen while wearing these items.

      5. Direct blow to the pierced area resulting in a laceration to you or to your
      opponent/teammate.

      4. Opponent/teammate catches the article and rips it from your body. Usually
      this results in the jewelry being damaged. If a teammate catches a 'ring of some
      sort with a finger, etc., the ring will be forcibly ripped from your body resulting in
      probable damage of the item and guaranteed damage to your body; not to mention
      the damage to your teammate's finger (It's called a tendon avulsion and requires
      surgery to repair.).

      3. Swallowing of the items. Internal organs to not like objects with points on the end.
      An Esophageal piercing is not very pretty. No one will notice your statement.

      2. Tooth damage by biting down on such items and breaking a tooth. Most dental
      plans will not pay for this type of dental repair and neither will the SFA Athletic
      Department.

      1. And the most life threatening way to injury yourself while wearing a tongue ring
         is asphyxiation. Should the tongue ring remove itself from your tongue and you
         breathe it into you lungs, it becomes a life threatening emergency that will
         require your immediate removal from the game/practice and it's immediate
         removal from your lungs.

At all pre-season meetings I addressed this situation and it seemed like you (the athlete)
understood the athletic training room's opinion. By the repeated actions of some athletes,
it is obvious that you did not understand that opinion. Let me be blunt:

         NO VISIBLE JEWELRY OF ANY TYPE WILL BE ALLOWED
                  DURING ANY PRACTICE OR GAME.
                  THE JEWELRY WILL BE REMOVED
                               OR
        YOU WILL BE REMOVED FROM THE PRACTICE OR GAME.

The Athletic Training Staff has been instructed to inform you that you need to remove it
and then inform your coach if you do not remove the problematic item. If you refuse,
you will be removed from practice and will not return until it is removed.
Covering is not removing. It just doesn't work.
Thank you for your cooperation in keeping yourself and your teammates as injury free as
possible.

I have read the above policy _________________________________________

                             „11 - '12 Academic Year

                                                                                       Page 11 of 19
                                            Female Athletes Only


The enclosed is for your protection and for the protection of your unborn child, should the situation occur. I
cannot force you to inform the medical staff that you have become pregnant; but I hope you will do what is in
the best interest of you and your unborn child - inform us so we can protect the health of both of you.


Table 29-2
                       American College of Obstetricians and Gynecologists (ACOG)
                          Guidelines for Exercise During Pregnancy (Feb. 1994)


An exercise prescription in pregnancy should be individualized and should include a health assessment.
It must be emphasized that none of these recommendations has a firm basis in prospective, randomized,
clinical trials.


These guidelines follow from a critical analysis of the available physiologic data regarding exercise and
pregnancy and represent reasonable extrapolations from such knowledge.


Recommendations for Exercise in Pregnancy and Postpartum


There are no data in humans to indicate that pregnant women should limit exercise intensity and lower target
heart rates because of potential adverse events. For women who do not have any additional risk factors for
adverse maternal or prenatal outcome, the following recommendations may be made.

1. During pregnancy, women can continue to exercise and derive health benefits even from mild-to-moderate
2. exercise routines. Regular exercise (at least three times per week) is preferable to intermittent activity.

3. Women should avoid exercise in the supine position after the first trimester. Such a position is associated
   with decreased cardiac output in most pregnant women; because the remaining cardiac output will be
   preferentially distributed away form splanchnic beds (including the uterus) during vigorous exercise, such
   regimens are best avoided during pregnancy. Prolonged periods of motionless standing should also be
   avoided.

4. Women should be aware of the decreased oxygen available for aerobic exercise during pregnancy. They
5. should be encouraged to modify the intensity of their exercise according to maternal symptoms. Pregnant
6. women should stop exercising when fatigued and not exercise to exhaustion. Weight-bearing exercises
7. may under some circumstances be continued at intensities similar to those prior the pregnancy throughout
   pregnancy. Non-weight-bearing exercises such as cycling or swimming will minimize the risk of and facilitate
8. the continuation of exercise during pregnancy.

4. Morphologic changes in pregnancy should serve as a relative contraindication to types of exercise in which
loss of balance could be detrimental to maternal or fetal well-being, especially in the third trimester. Further,
any type of exercise involving the potential for even mild abdominal trauma should be avoided.

**copied from ACSM‟s Handbook for the Team Physician**

I have read the recommendation of the American College of Obstetricians and Gynecologists.



                ___________________________________________
                                Please sign here



                                           '11 - '12 Academic Year

                                                                                                             Page 12 of 19
                                   Stephen F. Austin State University
                                        Department of Athletics
                                   DRUG TESTING CONSENT FORM


               I have received the attached copy of the "Stephen F. Austin State University
        Department of Athletics Drug Testing Program." I have read it, been given the chance
        to ask questions about it, and fully understand its provisions.


               I desire and agree to participate in the Program and to be subject to its terms. I
        accept the team physician or physicians employed by the University as my personal
        physicians for the limited purposed of overseeing my participation in the Program, the
        obtaining of urine specimens from me by the Program Administrators from time to time,
        the testing and analysis of such specimens (including testing and analysis for possible
        presence in my system of any amphetamines, steroids, marijuana-related substances,
        cocaine, or other drugs or controlled substances), the keeping of confidential records and
        results of such tests, and related activities as set forth in the Program. I agree to cooperate in
        furnishing my urine specimens from time to time as required.


                I further agree and consent to the disclosure of the records and test results relating to
        myself only to those persons and only under the circumstances described in the Program.
        This consent includes the possible release of the records and test results relating to myself, to
        my parents (or guardians) or spouse. Further, this consent is given pursuant to all state and
        federal laws governing privacy, public records, and education records, and is a waiver of my
        rights to non-disclosure of my records and test results only to the extent of the disclosures
        authorized in the Program.



        DATE: ____________________                          ______________________________________
                                                            SIGNATURE

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

                                                            ______________________________________
                                                            SOCIAL SECURITY NUMBER

                                                            ______________________________________
                                                            PARENT OR GUARDIAN




                                           '11 - '12 Academic Year
                                                                                                     Page 13 of 19
               STEPHEN F. AUSTIN STATE UNIVERSITY
                      ATHLETIC TRAINING
                 HEALTH HISTORY QUESTIONNAIRE

      I.                 SPECIFIC MEDICAL QUESTIONS:

Y/N            1. Have you been under the care of a physician, any time in the PAST 3 YEARS?
      If yes, please explain: ________________________________________
      __________________________________________________________
Y/N           2. Have you ever had any SURGERY (including pin, plate, fracture, etc.)?
                      If yes, please explain (date, site of injury, type of surgery)
                         Date: ____ / ____ / ________ Injury/Surgery:______________________
Y/N           3. Have you ever had any MAJOR injuries resulting from sports participation?
                      If yes, please explain: ________________________________________
                         __________________________________________________________
Y/N           4. Have you ever had any MAJOR injuries not resulting from sports participation?
                      If yes, please explain: ________________________________________
                         __________________________________________________________
              5. Have you ever had an illness or injury to any of the following organs?

Y/N                      a. Eyes: ___________________________________________________

Y/N                      b. Ears: ___________________________________________________

Y/N                      c. Heart: __________________________________________________

Y/N                      d. Lungs: __________________________________________________

Y/N                      e. Kidneys: ________________________________________________

Y/N                      f. Reproductive Organs: ______________________________________

Y/N                      g. Liver: ___________________________________________________

Y/N                      h. Other: __________________________________________________

              6. Immunizations (Date of last booster)
                                               Tetanus: ____ / ____ / ________
                                               MMR(measles, mumps, rubella): ____ / ____ / ________
              7. Gynecological Exam (Females)
                                       Date of last PAP Smear: ____ / ____ / ________
      II.                DISEASE & ILLNESS:

              Have you suffered from, or been told (by a physician or parent) that you
              have had:

Y/N   1. Diabetes                                  Y/N     2. Epilepsy
Y/N   3. Hepatitis                                 Y/N     4. Marfans Syndrome
Y/N   5. Measles                                   Y/N     6. Mononucleosis
Y/N   7. Mumps                                     Y/N     8. Rheumatic Heart Disease
Y/N   9. Scarlet Fever                             Y/N     10. Tuberculosis


                                 '11 - '12 Academic Year
                                                                                                 Page 14 of 19
        III.            ALLERGIES / MEDICATIONS:

                1. Do you suffer from:

Y/N                     a. Asthma: Type of Inhaler: ____________________________________

Y/N                     b. Hay fever

Y/N                     c. Skin Allergies: ____________________________________________

Y/N                     d. Other Allergies: ___________________________________________


Y/N             2. Have you ever been tested for: SICKLE CELL ANEMIA TRAIT (if applicable)?
                If yes, give date: ____ / ____ / ________ Please explain results:_____________
                ________________________________________________________________

Y/N             3. Are you presently taking any medications?
                        If yes, please explain: ________________________________________
                        __________________________________________________________

Y/N              4. Are you allergic to any medications?
(Please list any prescription, over the counter, and/or topical.) ____________________________
                        __________________________________________________________
        IV.             HEAD & NECK:

Y/N             1. Have you ever had a head/neck injury that has interrupted your athletic
participation? If yes, how long were you inactive?_________________________
Y/N             2. Do you have frequent headaches?
                If YES, how severe are they? ________________________________________
                Do you become dizzy? ______________________________________________
Y/N             3. Have you ever been knocked unconscious or suffered from a concussion in
the past three years? If yes, give date: ____ / ____ / ________
Y/N             4. Have you been knocked unconscious more than once?
                If yes, how often? __________________________________________________
Y/N             5. Have you ever been hospitalized for a head injury?
                If yes, when: ____ / ____ / ________ How long: __________________________
Y/N             6. Have you ever suffered from a pinched nerve of the arm or of whiplash?
                If yes, when: ____ / ____ / ________
Y/N             7. Have you ever been hospitalized for a neck injury?
                If yes, when: ____ / ____ / ________ How long: __________________________
Y/N             8. Do you suffer from pain, stiffness, or limited movement of the neck?
                If yes, please explain: ______________________________________________
Y/N             9. Have you ever been X-RAYED for a head or neck injury?




                                  '11 - '12 Academic Year
                                                                                                 Page 15 of 19
      V.              EYES:
Y/N           1. Do you wear glasses?
Y/N           2. Do you wear contacts?          If Y, Hard or Soft lenses (Please circle one)?
Y/N           3. Do you wear either of the above during sport activity?
      If the answers above are yes, name the prescribing consultant:
      ___________________________________               (______) ______ - ________
      Name of Physician                                 Phone
      VI.             DENTAL:
Y/N           1. Do you wear any dental appliance (braces, caps, etc.)?
                      If yes, please explain: ________________________________________
                      __________________________________________________________
              2. When were you last examined by a Dentist (for regular dental care)?
              Date: ____ / ____ / ________
      VII.            NOSE:
Y/N           1. Have you ever fractured your nose?
              2. Do you suffer from:
Y/N                   a. Sinus problems?
Y/N                   b. Frequent nose bleeds?
Y/N                   c. Nasal blockage?
      VIII.           HEART:
Y/N           1. Have you ever been told you have a heart murmur or palpitation?
              If yes, please explain: ______________________________________________
Y/N           2. Have you ever had any testing done on your heart?
              (Ex: stress test, EKG, Echocardiogram, etc.)_____________________________
              ________________________________________________________________
Y/N           3. Do you have chest pain during or after athletic activity?
      IX.             SKELETAL STRUCTURE:
Y/N           1. SHOULDER
              - Have you suffered from a shoulder injury that has incapacitated you
              (for more than two weeks) during the past THREE years?                      R/L
                      If yes, please explain: ________________________________________
                      __________________________________________________________
              2. ELBOW- Have you suffered from:
Y/N                   a. Sprains                                                          R/L
Y/N                   b. Hyperextension                                                   R/L
Y/N                   c. Dislocation                                                      R/L
Y/N                   d. Other: _____________________________________                     R/L




                                '11 - '12 Academic Year

                                                                                                 Page 16 of 19
           3. WRIST & HAND - Have you suffered from:
Y/N                a. Fractures                                                        R/L
Y/N                b. Sprains                                                          R/L
Y/N                c. Dislocations                                                     R/L
Y/N                d. Other: _____________________________________                     R/L
           4. BACK
Y/N                a. Have you ever suffered from a back injury?
Y/N                         If YES, did you see a physician?
Y/N                         Was you back X-RAYED?
Y/N                b. Do you experience frequent back pain?
Y/N                c. Have you ever suffered from an injury to the vertebral column?
Y/N                d. Have you been told that you have SCOLIOSIS?
           5. KNEE
Y/N                a. Have you ever suffered from a knee injury?                       R/L
Y/N                b. Were you ever told you had a ligament injury?                    R/L
Y/N                c. Were you ever told you had a meniscus (cartilage) injury?        R/L
Y/N                d. Have you ever suffered from Osgood-Schlater's Disease?           R/L
                            If YES, when? _______________________________________
           6. ANKLE
Y/N                a. Have you sprained an ankle in the past THREE years,
                   which incapacitated you for more than two weeks?                    R/L
Y/N                b. Have you ever had an injury involving the Achilles Tendon?       R/L
           7. FOOT - Have you suffered from:
Y/N                a. Fractures                                                        R/L
Y/N                b. Sprains                                                          R/L
Y/N                c. Arch Problems                                                    R/L
Y/N                d. Other: _____________________________________                     R/L
      X.           GENERAL MEDICAL DATA:
Y/N        1. Were you ever advised to a wear a brace or harness during physical activity?
                   If YES, what type: ___________________________________________
Y/N        2. Have you ever experienced illness or injury due to HEAT EXPOSURE?
                   If YES, explain: _____________________________________________
Y/N        3. Have you ever been treated for Ulcers?
Y/N        4. Have you ever suffered from or been told you have a Hernia?
                   If YES, where: ______________________________________________
                   Was it surgically repaired? Y / N When: __________________________
Y/N        5. Have you ever suffered from kidney infections?
Y/N        6. Do you suffer from frequent blisters or shin splints?
Y/N        7. Have you ever had any significant injury or illness (related or unrelated to
           athletics) not covered by any of the above questions?
                   If yes, please explain: ________________________________________
                   __________________________________________________________
                             '11 - '12 Academic Year
                                                                                             Page 17 of 19
Y/N             8. Has a physician ever advised you NOT to participate in contact sports or
                physical activity? If YES, please explain:________________________________


Y/N             9. If any SURGERIES have been performed, give the physician's name(s) and
                address, and obtain a copy of the surgery report and send to the Head Athletic
                Trainer for your medical records.
                ______________________________________ (______) ______ - ________
                Name of Physician                                        Phone
                ___________________________________________________________
                Street Address
                ___________________________________________________________
                City, State Zip
        XI.             FAMILY HISTORY:
                Check the following disease, if present, in any blood relation family
                member.
                If checked, state whom was affected.                             Relation
Y/N             1. Cancer                                                ___________________
Y/N             2. Diabetes                                              ___________________
Y/N             3. Heart Disease                                         ___________________
Y/N             4. High Blood Pressure                                   ___________________
Y/N             5. Blood Disease                                         ___________________
Y/N             6. Sickle Cell                                           ___________________
Y/N             7. Sudden Death, unexplained                             ___________________




We hereby certify the above questions are answered completely and truthfully to the best of our knowledge.




ATHLETE'S SIGNATURE: ______________________________ DATE: ____ / ____ / ________




PARENT/GUARDIAN SIGNATURE:________________________DATE: ____ / ____ / ________




                                   '11 - '12 Academic Year
                                                                                                 Page 18 of 19
                                               STEPHEN F. AUSTIN STAE UNIVERSITY                                        (Incoming Athletes)
                                                      ATHLETIC TRAINING
                                                        PHYSICAL EXAM

Name: _______________________________________________________________________                Date of Exam: _________ / __________ / _____________

Sport: ______________________________ SSN: ________ / ______ / ________ Student ID: _____________________________ Age: ________
             CHEERLEADING                                                                                                                         Sex: M /
F

Height: _______‟ ________”             Weight: ______________ lbs.     Blood Pressure: ___________ / ____________

Urine -                                      Glucose                    Upper Extremities

                                   Alb. / S.C. / Micro                                                      ROM / Atrophy
Blood -                              Hgb / WBC / hct                                                     Hx. Of Dislocation
Heart -                                      Rhythm
                                                             '11 - '12 Academic Year                 or significant trauma?
Lungs -                                         Ausc.                   Flexibility

                                            Percuss.                    Abdomen -                               LKS Palp?

                             TBC test (date / results)                                                               Hernia?
Lower Extremities                                                                                                    Scars?

                                 Assymetry / Atrophy                    Genitalia / Rectal

                             Hamstrings / Quadriceps                    Skin

                                 Valgus / Varus Legs                    Ears -                               Canal / Drum
Knees (1 - 3 degrees)                                                                                    Hearing - Spoken      R
                               Instability (MCL / LCL)                                                                Voice    L

                                         (ACL / PCL)                    Nose -                                       Septum

                                      Effusion / ROM                                                           Obstruction

                                      Past Surgeries                    Throat -                                      Mouth

                                  Significant History?                  Thyroid, Nodes
Feet / Ankles

Spine                                                                   Required Medication
Dental -                                      (Teeth)

                                       Cavities Index                   Remarks

                                           Occlusion                    Other Significant Info.

                                          T - M Joint

                                    3rd Molar Position                  Limitations or

                                             Hygiene                        Special Equipment
Eyes -                                  Pupil / Reflex

                                    Versions / Fields          /                                  M.D. Name (Please Print:

                                  Vision Uncorrected           /                                                  Address:

                                    Vision Corrected           /                                            City, State Zip:

                                 Objective Refraction          /                                             Office Phone:     (    )         -

                                      Internal Health                   HOLD - Further Testing

                                      External Health                   (Please Explain)
Other Remarks:

                                                                                                            - OR -
                                                                        “OK” - M.D. Signature




                                                               '11 - '12 Academic Year                                              Page 19 of 19