Dear Student-Athlete,

I want to remind you about some of the important policies and procedures for Rosemont College

Athletics and to inform you of how we will be doing medical paperwork this upcoming year.

First, the only medical paperwork that is required for returning student athletes are the following:

• Returner's Medical Update• Updated Insurance/Emergency contact information (including scanned current insurance

card)

• Concussion Acknowledgement

• HIPAA release

• Updated ADD/ADHD exemption form (if applicable)

All of the aforementioned forms can be found on the Rosemont College athletics’ website under the

“quick info” tab. All paperwork must be in possession of the athletic training staff in order to be

medically cleared to participate. The paperwork must be returned to the athletic training staff via email

which can be found below and on the athletics’ website under the “inside athletics” tab.

• Email: athletics@rosemont.edu

The athletic department has a secondary insurance policy through AG Administrators for athletic related

injuries. This plan has a $250 deductible which must be met by your primary insurance first. After the

deductible is met, the secondary insurance benefits are payable at 100% of usual reasonable and

customary charges. Therefore, it is necessary for you to possess primary insurance coverage and to

inform the Athletic training staff immediately of any loss or changes in primary insurance. If you have

primary insurance that requires a referral prior to seeing a physician, we recommend that you establish

care with a primary care physician in the nearby vicinity. Failure to do so prior to your athletic season

will result in withholding from athletic participation until a primary care physician has been

established.

Appointments of any athletic related injuries should be made through the athletic training staff. If you do

not wish to see our team physician concerning an athletic related injury, please notify the athletic training

staff of the details for any appointments. Appointments made and medical bills incurred without the

knowledge of the athletic training staff will be the responsibility of the student-athlete. When you visit an

outside physician for sickness/injury, it is required that you return with a note clearing you for

participation. If you have a surgical procedure or invasive treatment done the athletic training staff

requires surgical/treatment notes and a rehabilitation plan. Failure to do so will result in withholding

from athletic participation until all information is received.

If there are any questions regarding the medical requirements for athletic participation please contact the

athletic training staff.

Thank you and see you this upcoming Fall!

Rosemont College Medical Update for the

Returning Student-Athlete

Name:___________________________ Sport:____________ Year In School:__________Date of Birth:____________ Age:_____ Student-Athlete Cell #:_______________________ Parent (s)’ Name:_________________________________________ Phone#:________________ Parent (s)’ Address(Include city, state, zip code): __________________________________________________

Interim Medical History: To be completed by student-athletes returning to participation after less than 12 months absence.

1. Have you been hospitalized or had a major illness since the most recent medicalevaluation?......................................................................................................................

2. Are you currently ill in any way?...................................................................................... 3. Have you had an injury since the most recent medical evaluation?................................ 4. Do you currently have an incompletely healed injury?.................................................... 5. Are you currently taking medication on a regular or continuing basis?...........................

If yes, what?_______________________________________________________ 6. Are you taking any short course medication for a specific illness?..................................

If yes, what?_______________________________________________________ 7. Do you know of or believe there is any health reason why you should not participate in the

Rosemont College intercollegiate athletic program?..................................................... 8. Do you wish to see a physician for any reason?............................................................. 9. Do you plan on seeing a physician for any reason?........................................................

If yes, why?________________________________________________________ 10. Have you been exposed to or tested positive for COVID-19?.........................................

If yes, explain______________________________________________________

The undersigned, herewith, A. Understands that he or she must refrain from practice or play while injured or ill, whether or not

receiving medical treatment until he or she is discharged from treatment or is given permissionby the team physician to restart participation despite continuing treatment.

B. Understands that having passed the physical exam does not necessarily mean that he or she isphysically qualified to engage in athletics but only that the physician did not find a medicalreason to disqualify him or her at the time of the examination.

C. Understands that the Rosemont College team physicians make the final determination forreturn to participation

D. Certifies the above answers are correct and true.

Signature:_________________________________________________ Date:_____________________

_____________________________________________________________________________________

To be filled out by the Athletic Training Staff:

Height:______ Weight:______ Pulse:_________ B.P.:______________

Rosemont College Medical Update for

Returning Student-Athlete

Comments from yes answers on the interim medical history.

Athletic Trainer’s Signature: ____________________________________ Date:_______________

Rosemont College Athletics Insurance Information Form

RC Athletics requires verification of primary personal health insurance coverage for all student-athletes. RC athletics department provides an athletic injury insurance policy for injuries sustained by student-athletes while participating in intercollegiate athletics. This policy is “in excess” or “secondary” to any other collectible group or individual policy benefits. Therefore, for the athletic injury policy to pay benefits, the primary insurance coverage must be exhausted. The student-athlete will not be allowed to participate in any conditioning, practice, or competition until this form is completed and returned. Please be as thorough as possible.

Athlete’s Name: Date of Birth:

HMO:

Sport(s):

Local Address (room number, building): Phone Number:

Please complete the following and attach a copy of the front and back of your health insurance card (s).

Primary Health Insurance information

I am/will be covered only under the Rosemont College Student Health Insurance Policy. Yes No

Policy Holder’s Name: Date of Birth:

Relation to Student-Athlete:

Home Address:

Name of Insurance Company:

Policy #: Group#:

Mailing Address for Claims:

Telephone Number: Effective Policy Date: Exp Date:

Policy Limit: Policy Deductible: Co-Pay:

Does your insurance require: A second opinion for surgery Yes No Pre-auth for surgery Yes No

Do you have other secondary insurance Yes No. Please provide copies and information for the secondary policy:

Please answer the following questions. Does this insurance require pre-authorization of services from a primary care physician? Yes No If this policy is an HMO does it only cover services provided in your home state? Yes No Is your student-athlete on an insurance guest plan for out of state while attending RC? Yes No Can this student-athlete choose a primary care doctor in the state of PA? Yes No Are there any specific limitations to this policy we should know about? Yes No

Limitations:

Emergency Contact Information

Name:

Relationship to Student-athlete:

Daytime Phone Number:

Cell phone number:

I/we certify to the best of our knowledge that the above information is accurate and will notify Rosemont College Athletics Department of any changes if they occur during the upcoming academic year. I/we understand that the athlete must seek medical care and treatment immediately, if a covered accident occurs, in order to be eligible for benefits.

This is not a waiver of the student health insurance; please refer to Rosemont College student health insurance waiver for more information.

I hearby authorize a claim to be filed on my behalf under the above medical policy in the event of an athletic injury sustained by listed above.

Name of student-athlete:

Signature of student-athlete:

Name of parent or guardian (if under 18):

Signature of parent or guardian:

Date:

Student-Athlete Concussion Acknowledgement:

The Athletic Training Staff at Rosemont College recognizes that sport-related concussions pose a significant health risk for Rosemont College student-athletes. Therefore, the Athletic Training Staff has implemented policies and procedures to deal with the assessment, management, and return-to-play (RTP) considerations for student-athletes who have sustained a concussive episode based on the NATA Position Statement on Concussions. In addition, the Athletic Training Staff recognizes the importance of baseline testing on student-athletes who participate in sports which are recognized as contact or collision as well as those who have a history of concussions upon entering athletic participation at Rosemont College. Baseline concussion testing information will be extremely useful in RTP decisions. The baseline data, along with physical exam, diagnostic testing, symptom scaling, follow up testing and a gradual RTP protocol will all be used in conjunction with sound clinical judgment on an individualized basis to determine when it is safe for a student-athlete to return to competition.

COMMON SIGNS AND SYMPTOMS include but are not limited to:

Signs Observed: Signs Reported by Athlete: Appears to be dazed or stunned Headache Confused about assignment Nausea Unsure of game, score, or opponent Balance problems or dizziness Moves clumsily Double or fuzzy vision Answers questions slowly Sensitivity to light or noise Loses consciousness (even temporarily) Feeling sluggish Shows behavior or personality change Feeling “mentally foggy” Forgets events prior to hit (retrograde amnesia) Change in sleep patterns Forgets events after hit (anterograde amnesia) Concentration or memory problems Forgets plays Muscular weakness

BASELINE ASSESSMENT:

All incoming freshman and transferring student-athletes at Rosemont College who are participating in sports will have a baseline neurocognitive test performed by the Athletic Training Staff as part of their athletic medical screening. Currently, the Rosemont College Athletic Training Staff utilizes the ImPACT testing for all baseline assessments.

CONCUSSION MANAGEMENT:

In any circumstances where signs, symptoms, or behaviors consistent with a concussion in a student-athlete are observed or reported, the first priority is to remove the student-athlete from athletic activity until a thorough sideline assessment can be made. The sideline assessment will be performed by the Athletic Training Staff using the Sport Concussion Assessment Tool (SCAT 5) to determine if there is a possible concussion. Furthermore, if there is a question about the state of mental clearance, as determined by the Athletic Training Staff, it is best to err in the direction of a conservative assessment and withhold the student-athlete from further athletic activity until a physician assessment can be arranged. If a student-athlete is diagnosed with a

concussion, he/she shall be withheld from the competition or practice and not return to activity for the remainder of that day. The student-athlete will receive serial monitoring for deterioration. Student-athletes will be provided with written instructions upon discharge, preferably with a roommate, guardian, or someone that can follow the instructions. The student-athlete in collaboration with the Athletic Training Staff shall schedule an appointment to follow up with the team physician for all suspected concussions regardless of severity.

RETURN-TO-PLAY GUIDELINES:

The team physician has final authority to determine when the RTP protocol shall commence as well as when the student-athlete can return to full athletic activity. The SCAT-5 will be used to determine if a concussion has been sustained. RTP is a step wise symptom-limited program with stages of progression. The student-athlete should complete each level and progress to the next if he/she remains asymptomatic both at rest and with exercise. Generally, each step should take about 24 hours for a total of 5 days. Completing one step and moving on to the next is contingent upon finishing the prior day’s activity with no return of symptoms. Should the student-athlete become symptomatic during the progression, he/she should cease the day’s RTP activities, rest for a 24 hour period, and return to previous asymptomatic level. The RTP levels are as follows:

• Rest until asymptomatic (physical and mental rest) • Post-concussion testing using ImPACT • Light aerobic exercise (exercise bike) • Heavy aerobic exercise (treadmill, laps, etc.) • Sport specific exercises w/ heavy aerobic exercise • Non-contact training drills • Full contact training after medical clearance • Return to competition (gameplay)

STUDENT-ATHLETE RESPONSIBILITIES:

It is the student-athlete’s responsibility to report ALL injuries and symptoms including possible concussion symptoms to the Athletic Training Staff. If a student-athlete fails to report possible concussion symptoms, he/she risks the chance of experiencing Second Impact Syndrome. This occurs when someone, who has already sustained a head injury, sustains a second head injury before the symptoms have cleared from the first injury. Many times this occurs because the student-athlete has returned to competition and plays before his/her first injury symptoms resolve. Second Impact Syndrome can result in unconsciousness, cessation of breathing, and ultimately death. Therefore, it is imperative that all Rosemont College student-athletes report any and all possible concussion symptoms to the Athletic Training Staff. It is better to miss one game than the whole season. When in doubt, get checked out.

I hereby accept responsibility for reporting all injuries and illnesses to the Athletic Training Staff, including signs and symptoms of concussions. I have read and reviewed the aforementioned information as well as the NCAA Concussion Fact Sheet provided to me. I understand the risks associated with not reporting any injury or illness I sustain, including concussions, and continuing participating in athletic activities.

____________________________________________________ _______________

Signature of Student-Athlete (or Parent/Guardian if under 18) Date

After reading the NCAA Concussion fact sheet, I am aware of the following information:

_____ A concussion is a brain injury, which I am responsible for reporting to my team physician

or athletic trainer.

_____ A concussion can affect my ability to perform everyday activities, and affect reaction

time, balance, sleep, and classroom performance.

_____ You cannot see a concussion, but you might notice some of the symptoms right away.

Other symptoms can show up hours or days after the injury.

_____ If I suspect a teammate has a concussion, I am responsible for reporting the injury to my

team physician or athletic trainer.

_____ I will not return to play in a game or practice if I have received a blow to the head or

body that results in concussion-related symptoms.

_____ Following concussion the brain needs time to heal. You are much more likely to have a

repeat concussion if you return to play before your symptoms resolve.

_____ In rare cases, repeat concussions can cause permanent brain damage, and even death.

____________________________________________________ _______________ Signature of Student-Athlete (or Parent/Guardian if under 18) Date

____________________________________________________ Printed name of Student-Athlete

Rosemont College HIPAA Release Form

Authorization for Release of Medical Information to Faculty, Coaches, & Athletic Staff:

I, _____________________________, hereby authorize all members of the Rosemont College

Athletic Training Staff, all Rosemont College Team Physicians, or any other physicians or health

care professionals to release information, records, and reports regarding my medical history,

medical status, record of injury and/or surgery, prognosis, diagnosis, record of serious illness,

rehabilitation, and related personally identifiable health information to faculty, coaches, and

athletic staff. The information includes injuries or illnesses relevant to past, present, or future

participation in athletics at Rosemont College.

The reason for this disclosure is to advise my faculty, coaches, and athletic staff of the nature,

diagnosis, prognosis, or other treatment concerning my medical condition and injuries/illnesses

sustained while I am a student-athlete. I understand that the entities receiving the information

are not health care providers or health plans covered by federal privacy regulations, and that the

information described above may be disclosed publicly.

I understand that Rosemont College will not receive compensation for its use/disclosure of the

information. I understand that I may refuse to sign this authorization and that my refusal to sign

will not affect my ability to obtain treatment. I may inspect or copy any information

used/disclosed under this authorization. I understand that I may revoke this authorization at any

time by notifying in writing to the Head Athletic Trainer, but if I do, it will not have any effect

on actions the college took in reliance on this authorization prior to receiving the revocation.

This authorization expires six years from the date it is signed.

A photocopy of this authorization shall be considered as valid as the original.

Name: __________________________________________ Date: ___________________

Sport(s): ________________________________________ D.O.B: _________________

Signature: _________________________________________________________________

Signature of Parent/Guardian if athlete is under age 18:

Signature: _______________________________________ Date: ___________________