Washington & Jefferson College Athletics NCAA Mandatory Sickle Cell Waiver Form

Some quick facts about Sickle Cell Trait:

• Although sickle cell trait is most predominant in African-Americans and those of Mediterranean, Middle

Eastern, Indian, Caribbean, and South and Central American ancestry, persons of all races and ancestry may test

positive for sickle cell trait.

• It’s a generally benign condition in which a person inherits from their parents one gene for the oxygen-

carrying element in their red blood cells – hemoglobin – and one gene for sickle shaped hemoglobin. It is not the

same as the more severe condition, sickle cell disease, in which both genes for sickle hemoglobin are inherited. It

is noted that those with the trait do experience normal healthy lives. Only in situations where the body is pushed

to extreme conditions, as athletes do, can the trait sometimes turn normal red blood cells to sickle cells. In this

instance, red blood cells change from a normal disc shape to a crescent or “sickle” shape, which can accumulate in

the bloodstream and “logjam” blood vessels, thus denying oxygen to muscles and organs. But in most cases,

carriers of the trait live normal, healthy lives without incident. Complicating factors include extreme exertion,

increased heat, altitude and dehydration.

• Washington and Jefferson College Sports Medicine Department highly recommends that you please click

on the website below for more information regarding sickle cell trait, including the NCAA fact sheet.

http://www.ncaa.org/health-and-safety/medical-conditions/sickle-cell-trait

Sickle Cell trait Testing

• The NCAA recommends that all NCAA Division III student-athletes have knowledge of their sickle cell trait

status. Sickle cell trait testing in the form of a blood test can be done by the student-athlete’s personal primary

care physician.

• Washington and Jefferson College recommends that all student-athletes who are unable to confirm their

sickle cell trait status undergo sickle cell trait testing prior to participation in any intercollegiate athlete activity. .

Testing generally costs around $5-$50 depending on the testing site. THIS EXPENSE IS THE RESPONSIBILITY OF THE

STUDENT-ATHLETE.

Test Results or Sickle Cell Trait Testing Waiver

After reviewing the above information and the NCAA Fact Sheet for Student-Athletes, I have elected to (please

check one of the boxes below and sign and date the appropriate lines):

□ I will provide documented proof of my Sickle Cell Trait status from previous testing to the Washington and

Jefferson College Sports Medicine Department (as well as, circle the results of my test below):

Test Results (please circle one ): Positive Negative

Student-Athlete’s Name _________________________________________________Date_________________

Physician or Test Administrator ___________________________________________Date_________________

□ I, _____________________________understand and acknowledge that the Washington and Jefferson

(Student-Athlete Name)

College Department of Athletics, the Washington and Jefferson College Sports Medicine Department and the NCAA

recommends that all Division III student-athletes have knowledge of their sickle cell trait status. Additionally, I have

read and fully understand the aforementioned facts about sickle cell trait testing.

Recognizing that my true physical condition is dependent upon an accurate medical history and a full disclosure of

any symptoms, complaints, prior injuries, ailments and/or disabilities experienced, I hereby affirm that I have fully

disclosed in writing any prior medical history and/or knowledge of sickle cell trait status to the Washington and

Jefferson College Sports Medicine Staff.

By signing this wavier, it shows that I do not wish to undergo sickle cell trait testing and I voluntarily agree to

release, discharge, indemnify, and hold harmless Washington and Jefferson College, its board, employees, and any

one affiliated with its Sports Medicine Department from any and all costs, liabilities, expenses, claims demands, or

any loss or personal injury that might result from my non-compliance with the recommendation of the NCAA and

Washington and Jefferson College.

I have read and signed this document with full knowledge that I am waiving my rights for sickle cell trait testing. I

have been educated in the condition and have been given a website to access any further information. I am

competent to sign this wavier and recognize the significance of this condition.

Student-Athlete Signature ________________________________________________ Date ___________________

Parent/Guardian Signature (if under the age of 18)____________________________________________________

Date_______________