Health and Injury Information, Consent for Medical Treatment, and Policies / Procedures

Parent/Guardian Information

In an emergency, please contact:
Parent/Guardian 1 *

First NameLast Name
Parent/Guardian 1 Phone Number
Please enter a valid phone number.
Parent/Guardian 1 Place of Work
Parent/Guardian 1 Work Phone Number
Please enter a valid phone number.
Parent/Guardian 2

First NameLast Name
Parent/Guardian 2 Phone Number
Please enter a valid phone number.
Parent/Guardian 2 Place of Work
Parent/Guardian 2 Work Phone Number
Please enter a valid phone number.
Other Emergency Contacts

In an emergency, when a parent/guardian cannot be notified, please contact the below. Please note that only domestic contacts may be used in case of emergencies.
Emergency Contact 1*

First NameLast Name
Emergency Contact 1 Phone*
Please enter a valid phone number.
Emergency Contact 2

First NameLast Name
Emergency Contact 2 Phone
Please enter a valid phone number.

Insurance Information

Southwestern Community College has insurance for our student-athletes in a secondary nature. If you have questions or inquiries, please contact the school. If you have no insurance, please indicate so, DO NOT LEAVE THIS BLANK.
Do you have health insurance?*
Insurance Company Name*
Insurance Company Phone Number
Please enter a valid phone number.
Policy Holder's Name*

First NameLast Name
Policy Number*
Group Number*
Please take a picture/scan of the FRONT of the insurance card and upload HERE:*

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Please take a picture/scan of the BACK of the insurance card and upload HERE:*

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Consent for Treatment and Disclosure of Education Records

Iowa law requires a parent’s, or legal guardian’s, written consent before their son or daughter can receive emergency treatment, unless, in the opinion of a physician, the treatment is necessary to prevent death or serious injury. As the parent(s), or legal guardian(s), of the child named above, I (we) authorize first aid, use of modalities, emergency medical treatment of hospitalization that is necessary in the event of an accident or illness of my (our) child. I (we) understand that this written consent is given in advance of any specific diagnosis or hospital care.
I hereby authorize the Athletic Training Staff acting on behalf of Greater Regional Health ("GRH Athletic Training Staff") to evaluate and treat any injury as it pertains to my participation in athletics at Southwestern Community College ("School"). Athletic training” means the practice of prevention, recognition, assessment, physical evaluation, management, treatment, disposition, and physical reconditioning of athletic injuries that are within the professional preparation and education of a licensed athletic trainer and under the direction of a licensed physician. This includes all reasonable and necessary preventive care, treatment, and rehabilitation for these injuries. I hereby acknowledge receipt of the Greater Regional Health Hospital Notice of Privacy Practices. School may disclose personally identifiable information from my education records to GRH Athletic Training Staff as determined appropriate by the School for purposes of my participation in athletics and receiving this evaluation and treatment.

**If not signed, consent to treatment is WAIVED unless deemed a medical emergency**
Parent/Guardian Signature (or student if over the age of 18) for consent for medical treatment:*

Clear
Time*

Hour Minutes

AM/PM Option
Date*

MonthDayYear
Date
Authorization For Release of Health Information

I hereby authorize Greater Regional Health Hospital and Clinics (“GRH”) to disclose to Southwestern Community College ("School") athletic coaches and/or other School officials my protected health information created or obtained by the GRH Athletic Training Staff in the course of conducting athletic training services. This disclosure is made at my request.
GRH may disclose any and all information which it has created or obtained regarding my care through the athletic training services.
I understand and acknowledge that:
1. I can revoke this Authorization at any time by giving my written revocation to GRH at the following address: c/o HIMS 1700 W Townline Creston, IA 50801. My revocation is not effective as to disclosures already made and actions already taken in reliance upon this Authorization.
2. GRH may NOT condition treatment, enrollment, or eligibility for benefits on whether I sign this Authorization.
3. I am authorizing disclosure of information protected under federal law. This information, once disclosed, may be subject to re-disclosure by the recipient and no longer be protected by state or federal law.
4. This Authorization is effective for one (1) year from the date on which it is signed.

A photocopy or exact reproduction of this signed Authorization shall have the same force and effect as the original.
Student-Athlete Full Name*

First NameLast Name
Student-Athlete Date of Birth*

MonthDayYear
Date
Parent/Guardian Signature (or student if over the age of 18) for consent to consult:*

Clear
Time*

Hour Minutes

AM/PM Option
Today's Date*

MonthDayYear
Date
Concussion Fact Sheet

Concussions and head injuries are very serious. Please indicate any above and please read the below information.
As a student-athlete, I have received the Concussion Fact Sheet for Student-Athletes (please click and read through link). I understand the nature and risk of concussion and head injury to student-athletes, including the risks of continuing to play after concession or head injury. I agree to inform the coaches and athletic trainer of any concussion symptoms that I encounter.

Link to the concussion fact sheet: http://fs.ncaa.org/Docs/health_safety/ConFactSheetsa.pdf
Signature of Student-Athlete*

Clear
Signature of parent/guardian (if student-athlete is under the age of 18)

Clear

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT

IN CONSIDERATION of being permitted to participate in any way in the Southwestern Community College athletics sporting event or practice held at a location and under the discretion of Southwestern “the Event”, EACH OF THE UNDERSIGNED hereby agrees, on behalf of myself and/or my child (if applicable): 1. The Activities associated with the Event may be dangerous and involve the risk of serious injury and/or death and/or property damage. I (and/or my child) can safely meet the physical and mental demands of the activity. 2. To release, waive, discharge, and covenant not to sue Southwestern Community College, its officers, board members, employees or agents (“Released Parties”) for any and all loss or damage, and any claim or demands therefor on account of any injury to persons or property or death arising out of or related to the Event, whether caused by the negligence of the Released Parties or otherwise. 3. To assume full responsibility for any risk of bodily injury, death or property damage arising out of or related to the Event whether caused by the negligence of Released Parties or otherwise, including the costs of any medical attention provided to me (and/or my child). 4. To indemnify and save and hold harmless the Released Parties and each of them from any loss, liability, damage, or cost they may incur arising out of or related to my (and/or my child’s) participation in the Event, whether caused by the negligence of the Released Parties or otherwise. 5. That this Release and Waiver of Liability, Assumption of Risk and Indemnity Agreement extends to all acts of negligence by the Released Parties and is intended to be as broad and inclusive as is permitted by the laws of the State in which the Event is conducted and that if any portion there is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT. I FULLY UNDERSTAND ITS TERMS. I UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIALRIGHTS BY SIGNING IT, AND I HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANYINDUCEMENT, ASSURANCE OR GUARANTEE BEING MADE TO ME, AND I INTEND MY SIGNATURE TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABLITY TO THE GREATEST EXTENT ALLOWED BY LAW.
Student-Athlete's Signature*

Clear
Parent/Guardian Signature (if student-athlete is under the age of 18)

Clear
Time*

Hour Minutes

AM/PM Option
Date*

MonthDayYear
Date

Drug & Alcohol Policy

Illegal usage and/or possession of alcohol and possession and/or usage of illegal drugs.The following policies will be in effect for all Southwestern student-athletes from the first day of them representing the Spartans (move-in, practice, classes begin, etc.) until athletic eligibility has been exhausted at Southwestern Community College.
Illegal Usage or Possession of Alcohol and/or Illegal Drugs
First Offense

Suspension from competition until 5 hours of community service has been completed. Approved and agreed upon by head coach, athletic administration, and Dean of Student Services. Other expectations at coach discretion.
Second Offense

Suspension for 10% of total competitions scheduled for the current regular season, and until 10 additional hours of community service has been completed. Approved and agreed upon by head coach, athletic administration, and Dean of Student Services. Other expectations at coach discretion.
Third Offense

Suspension for 25% of total competitions scheduled for the current regular season, and until 20 additional hours of community service has been completed. Approved and agreed upon by head coach, athletic administration, and Dean of Student Services. Other expectations at coach discretion.
Fourth Offense

Permanent dismissal from the team for the current academic year, will result in forfeiture of pro-rated portion of athletic scholarship.
These rules and consequence will be in effect for the entire calendar year once initial attendance at SWCC has occurred. If an athlete’s specific sport is done for that school year the punishment will take place the following year. All incidents will be evaluated on a case-by-case basis by athletic administration and/or Dean of Student Services. The consequences listed above are the minimum consequences. Athletic administration, head coach and/or Dean of Student Services reserves the right to impose additional consequences upon an evaluation of each individual case.
Student-Athlete Signature*

Clear
Date*

MonthDayYear
Date

Student-Athlete Certification

I hereby certify that all of the above and aforementioned information is accurate to the best of my knowledge.
Student-Athlete Signature*

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Parent / Guardian Signature (if student-athlete is under the age of 18)

Clear
Time*

Hour Minutes

AM/PM Option
Date*

MonthDayYear
Date
Please verify that you are not a robot and fully understand your submission.*
Should be Empty:

Health and Injury Information, Consent for Medical Treatment, and Policies / Procedures

Parent/Guardian Information

Other Emergency Contacts

Insurance Information

Student-Athlete Health History

Consent for Treatment and Disclosure of Education Records

Authorization For Release of Health Information

Concussion Fact Sheet

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT

General Data Protection Regulation

Photo / Video Release

Drug & Alcohol Policy

Illegal Usage or Possession of Alcohol and/or Illegal Drugs

First Offense

Second Offense

Third Offense

Fourth Offense

Student-Athlete Certification