Emergency Contact (if a parent cannot be reached)
The NJCAA discourages colleges from providing coverage or paying for expenses related to illness or conditions which are not sustained as the direct result of an accident in our intercollegiate sports program (THIS INCLUDES PRE-EXISTING CONDITIONS AND NON-ATHLETIC INJURIES). The athletic department accident insurance at South Plains College (SPC) provides coverage for each student-athlete while participating in official team practice, weights, conditioning, or games of intercollegiate sports. However, this insurance policy is an EXCESS policy. It is a SECONDARY carrier to the student-athlete’s primary coverage. It will only pay after his/her insurance company had paid or denied a claim.
SPC will not pay for medical services, or prescriptions, which have not been coordinated through the athletic trainer.
All medical bills for student-athletes incurred as a result of an accident in intercollegiate athletics will be sent to their home address unless SPC has instructed vendors otherwise.
· Submit bills incurred to your primary insurance first (if applicable). SPC’s insurance serves as a secondary policy to the student’s primary insurance. If the student is not covered under any other policy, SPC’s insurance becomes the primary insurance.
· Once your primary insurance (if any) processes the claim, submit a copy of the explanation of benefits of your insurance and itemized bills to the SPC Athletic Training Department. The claim will be sent from SPC to our insurance carrier’s office for processing.
· The college’s accident policy pays only up to its limits, and in some cases, may not pay the entire claim. Please note that claims will be in the student-athlete’s name and will ultimately become their responsibility to pay amounts not covered by the school’s insurance policy. South Plains College is not responsible for any balance on medical bills after the school insurance plan has paid its benefit.
PLEASE NOTE: If the student-athlete’s primary coverage requires pre-authorization or student-athlete must be seen by a specific PCP, you must follow the proper procedure required by your plan in order for the college’s insurance to satisfactorily complete its portion of the claim. It’s the responsibility of the student-athlete and/or parent to notify the athletic training staff of such requirements.
· Vision/Eye, Dental, and Medication expenses which are a direct result of an injury while participating in SPC intercollegiate athletics will be covered by the athletic department. Any other expenses not related to an injury will not be covered.
· The SPC athletic department will not be responsible for injuries that occur outside the formal confines of scheduled practices and games.
· SPC cannot cover any pre-existing conditions incurred prior to participation in athletics at SPC. This includes congenital defects, like asthma; medications such as inhalers are the responsibility of the student-athlete.
· Non-athletic injuries/illnesses are the student-athlete’s/parent’s financial responsibility. Although the SPC athletics does not assume financial responsibility for non-athletic injuries/illnesses and prescriptions, we will assist the student-athlete in arranging appointments with the appropriate physicians when at all possible.
· Once an athlete ceases participation in SPC athletics, the athletic department and college will no longer share the responsibility for new injuries. Furthermore, after one year, the college will not be responsible for claims made on injuries that occurred while participating in SPC athletics.
BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE SUMMARY OF SPC’S SUPPLEMENTAL ATHLETE INSURANCE COVERAGE AND CLAIM PROCEDURES.
AFFIDAVIT OF NO MEDICAL HEALTH INSURANCE
I, First Name Last Name, due hereby swear that I have no medical health insurance for payment of medical bills associated with any injury to me sustained during participation in intercollegiate athletics. I hereby state that I am not qualified to collect for medical benefits under the policy of any relative with whom I may, or may not, reside with.
· Understand that SPC athletics provides pre-participation physical evaluation yearly. It is required as a part of our medical information process. I must provide a detailed medical history as a part of this evaluation.
· Understand that passing the pre-participation exam does not necessarily mean that I am physically qualified to participate in intercollegiate athletics at SPC, but only that the evaluator did not find a medical reason to disqualify me at the time of examination.
· Understand that I should refrain from practice or play while injured or ill, whether or not receiving medical care. When under medical care I may not return to participation until I have been given permission by a medical professional, based on their independent professional judgment, after reviewing my condition, and fitness for the rigors of my sport. Clearance to return to participation may occur during or at the conclusion of my medical treatment.
· Understand and agree that if there is an injury/illness or change in health status it is my responsibility to inform my head coach AND athletic training staff and adhere to the aforementioned return to play guidelines listed above.
· Understand that I must hear the proper equipment as dictated by the rules of the sport. I may also have to wear padding or braces as indicated by the athletic training staff or medical personnel. Failure to do so may put me at risk for further injury.
Consent to Medical Treatment
I do hereby grant permission to physicians, athletic trainers, and/or any other qualified medical professionals associated, assisting, or employed in connection with South Plains College athletics, to render any preventive, emergency, surgical or rehabilitative medical treatment or care deemed reasonable and necessary for my health and well-being. If, in the instance of my incapacitation, I hereby request that the Athletic Trainer of South Plains College seek reasonable and necessary medical treatment on my behalf and is hereby authorized to choose treatment providers, plans, and facilities on my behalf.
Drug Testing Consent
I hereby give my consent to a urinalysis drug test, to be administered by South Plains College, at their discretion. The results of the said test will be kept confidential and can only be viewed by my coach, athletic trainer, team physician, athletic director, and myself.
If the results of the said test show a positive use of illegal drugs, a decision concerning my participation in athletics at South Plains College will be made at that time by my coach, and athletic director. The decision is one of the following:
1) Suspension from the team; with counseling
2) A probationary period; with counseling
3) Removal from team and loss of scholarship
Furthermore, I understand that a positive result automatically results in future retests.
I understand that refusal to sign this form could result in my dismissal from the team at the discretion of my coach. I also understand that refusal to give a sample or appear when selected for a urinalysis drug test will count as an automatic positive test.
I also understand that I have the right to request a said test at my own discretion.
VOLUNTARY ASSUMPTION OF RISK AND RELEASE OF LIABILITY
CAUTION: THIS IS A RELEASE OF LEGAL RIGHTS. READ AND UNDERSTAND IT BEFORE AGREEING. South Plains College is a non-profit educational institution. References to South Plains College ("College") include South Plains College, its officers, officials, employees, volunteers, students, agents, and assigns.
I freely choose to participate in athletics at South Plains College (henceforth referred to as the Program). In consideration of my voluntary participation in this Program, I agree as follows:
INSTITUTIONAL ARRANGEMENTS: I understand that College is not an agent of, and has no responsibility for, any third party which may provide any services including food, lodging, travel, or other goods or services associated with the Program. I understand that College is providing these services only as a convenience to participants and that accordingly, College accepts no responsibility, in whole or in part, for delays, loss, damage or injury to persons or property whatsoever, caused to me or others prior to departure, while traveling or while staying in designated lodging. I further understand that College is not responsible for matters that are beyond its control. I acknowledge that College reserves the right to cancel the trip without penalty or to make any modifications to the itinerary and/or academic program as deemed necessary by College.
INDEPENDENT ACTIVITY: I understand that the College is not responsible for any loss or damage I may suffer when I am traveling independently, or I am otherwise separated or absent from any College activity. In addition, I understand that any travel that I do independently on my own before or after the College sponsored Program is entirely at my own expense and risk.
HEALTH AND SAFETY: I have been advised to consult with a medical doctor with regard to my personal medical needs. I state that there are no health-related reasons or problems that preclude or restrict my participation in this Program. I have obtained the required immunizations, if any. I recognize that College is not obligated to attend to any of my medical or medication needs, and I assume all risk and responsibility therefore. In case of a medical emergency occurring during my participation in this Program, I authorize in advance the representative of the College to secure whatever treatment is necessary, including the administration of an anesthetic and surgery. To the extent necessary to provide such treatment, I grant the College access to any information governed by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 42 USC 1320d and 45 CFR 160-164. College may (but is not obligated to) take any actions it considers to be warranted under the circumstances regarding my health and safety. I agree to pay all expenses relating thereto and release College from any liability for any actions.
TRAVEL CHANGES: If I become separated from the Program group, fail to meet a departure airplane, bus, or train, or become sick or injured, I will, to a reasonable extent, and at my own expense seek out, contact, and reach the Program group at its next available destination.
TRAVEL IN A PERSONAL VEHICLE: If a student chooses to travel in their own vehicle or a vehicle personally owned by another individual, the owner and the owner’s liability insurance will be responsible for damages related to the vehicle or occupants. The driver of the personal vehicle should have a currently valid driver’s license and up-to-date liability insurance. I understand that travel in a personal vehicle is my choice and not a requirement or a recommendation from SPC.
ASSUMPTION OF RISK AND RELEASE OF LIABILITY: Knowing the risks described above, and in voluntary consideration of being permitted to participate in the Program, I agree to release, indemnify, and defend College and their officials, officers, employees, agents, volunteers, sponsors, and students from and against any claim which I, the participant, my parents or legal guardian or any other person may have for any losses, damages or injuries arising out of or in connection with my participation in this Program.
ACCEPTANCE: Submission of this form indicates agreement with the Voluntary Assumption of Risk and Release of Liability information above. I have carefully read this Release Form and acknowledge that I understand it. No representation, statements, or inducements, oral or written, apart from the foregoing written statement, have been made. This Release Form shall be governed by the laws of the State of Texas which shall be the forum for any lawsuits filed under or incident to this Release Form or to the Program. If any portion of this Release Form is held invalid, the rest of the document shall continue in full force and effect.
As a student-athlete, I recognize that my health relates directly to my ability to participate in training and competition in my sport. South Plains College (SPC) health care providers and athletic department need to be informed regarding my health so that the best decisions can be made regarding my participation. I understand that medical information may contain information protected by federal and state laws.
Recipients & Health Information to Be Released
This authorization permits any physician, physician assistant, athletic trainer, nurse, and/or another healthcare professional who has treated or assisted in my treatment for any injury, illness or physical or medical condition to disclose to SPC and its designees (athletic trainers, team health care providers, and coaches) protected health information in connection with my participation in intercollegiate athletics at SPC. This information may pertain to my medical status, medical condition, injuries, prognosis, diagnosis, and related personal identifiable health information. This information includes injuries or illnesses relevant to past, present, or future participation in intercollegiate athletics.
NOTICE: Requests of protected health information from recruiters/scouts are non-routine uses and authorizations for such disclosures will be required prior to the release of any protected health information.
This authorization remains in effect for one calendar year from the date of authorization. I understand that I may revoke this authorization in writing at any time by notifying the Head Athletic Trainer, but if I do, it will not have any effect on actions the college has taken prior to receiving the revocation.
POTENTIAL FOR REDISCLOSURE: Once your health information has been disclosed, the law does not always require the receiver of your information to keep your information confidential.
With this understanding, I hereby authorize health care providers, and/or SPC athletics to use or disclose information from my medical records for purposes related to my ability to participate in my sport, including but not limited to treatment, assessment, training needs, and payment.
Limited Authorization to Press/Public:
I, further authorize the SPC athletic department to release limited information to members of the press regarding my ability to participate in SPC athletics. Information will be limited to:
· Summary of Athletic Injury
· Ability to Participate in SPC athletics
Once you click "next form" you will be directed to the medical history form. DO NOT close the window. This form must also be completed.