Student Athlete Sports Medicine Packet for New Students and Transfers
Instructions:
1) The information in this packet is for College of Southern Maryland Athletics. Please complete all of the enclosed forms. They must be returned to CSM Athletics Department by:
□ Fall Sports (MSOC, WSOC, Volleyball, Cross Country): July 18th , 2014 □ Winter Sports (MBB, WBB): August 22nd, 2014
□ Spring Sports (Baseball, Softball, MLax, WLax, Golf): August 29th, 2014
2) Please use an ink pen (not a pencil) when completing these forms.
3) A completed sports medicine packet includes the following, and must be
complete in order to participate in any practice. If you are missing any of the
information you will not be allowed to participate, until the completed packet is turned in.
□ Eligibility Affidavit
□ Medical History (Please review with your parent/guardian) □ Physical (Performed and signed by an MD, DO, CRNP, or PA) □ Statement of Informed Consent
□ Student Athlete Code of Conduct
□ Copy of Insurance Card (Front and Back copy) □ Copy of your High School Diploma
□ Copy of your High School Transcript (If home schooled, you need a
notarized transcript)
□ Official college transcripts (This is for Transfer students, you must
include a transcript for each of the colleges you attended) 4) Return Forms to:
□ You can turn your forms into Sarah Williams (PE 207C) or Nick Williams
(PE207B) in the Athletics Department, located in the PE building on the La Plata Campus. Or
□ You can mail them in to
Attention: CSM Athletics Department PO Box 910
La Plata, MD 20646-0910
• Please note: If the student athlete is considered a minor, the signature of a parent/legal guardian is required.
• Final note: If the student athlete requires the use of some form of medication unique to him/her (that is, an asthma inhaler, an epi-pen), please bring an extra one to be placed in the training kit to be used as a back-up in emergency situations.
COLLEGE OF SOUTHERN MARYLAND
INTERCOLLEGIATE ATHLETICS
ELIGIBILITY INFORMATION
SPORT:
MALE / FEMALE DATE:
The following information is required for each student athlete.
Name:
(First, Middle, Last)
Date of Birth:
College I.D. #:
Seasons of Participation: First Year
Second Year
High School Graduation Date (month/year):
High School Attended:
(Name, City, State & Country)
GED:
Yes
No
GED Date Earned (month/year)
Date of Initial College Enrollment:
Transfer Student:
Yes No
If yes, from where
Office Use Only
NJCAA Online EligibilityFirst Name Fall Spring
Middle Name Full Time Terms Prev
Enrolled
Last Name Prev. FT Term Hrs. Earned
Date of Birth GPA
High School Status HS+3 HS-3 Cumulative Hrs Earned
ID Number GPA
Seasons of Participation Enrollment in Current Term High School Graduation Date of Physical
High School Name Exceptions
High School City, State Certified Learning Disabled
GED YES NO Academic Hardship
GED Date 18 months Non-Attend
Transfer Student YES NO Art. V Sec. 4e3
NJCAA Eligibility Affidavit
SPORT:______________________
Date:_____________
Fill in all applicable information on this form to assist in determining eligibility for the NJCAA.Personal Information:
Name
: ________________________________
Birth Date: __/__/____
CollegeID Number:__________
(First, Middle, Last)
Student’s College Address
: ____________________________ ________________________________
Street Address City, State, Zip Code
Student Athlete Cell Number: ________________________________ Email Address: _______________________
Other Information:
Parent’s Home Address
: ___________________________ __________________________________
Street Address City, State, Zip Code
Phone Number: ________________________________ Parents’ Names: ________________________________
Foreign Born Students:
Do you have an I-20 Form on file at this college? Yes _____ No _____
High School Information:
Name of High School(s) you have attended
: _________________________________________________
City, State & Country
: ________________________________________________________________
Did you graduate?: Yes* _____ No _____ High School Graduation Date (month/date/year):
__/___/____
Were you home schooled? Yes _____ No _____ Did you graduate? Yes* _____ No _____Check here if you have earned a *GED: ______ GED: Date Earned (month/date/year):
__/___/____
Did you attend three or more year of high school in the United States? ______ Yes _______ No
* Enclose a COPY of your High School Transcript, and GED Certificate (if applicable). Home School Transcripts must be notarized.
Additional Information:
1. Did you take any college credit classes while in high school? Yes* _____ No _____
* If yes, from what college(s)?
_________________________________________________________
* If yes, those transcript(s) from each college must be on file at this college.
2. Have you ever signed a Letter of Intent form with any institution? Yes _____ No _____
If yes, specify the College: __________________________________ Date (day/month/year): ____/____/______
3. Have you ever participated in a sport in a country other than the United States? Yes _____ No _____
Sport(s)? _______________________ Country: ________________________ Dates: ___________________
If yes, describe the situation: ______________________________________________________________________
______________________________________________________________________________
4. Have you ever been red-shirted for a season? Yes _____ No _____
If yes, list the dates of that season, name of college, and describe the situation.
________________________
______________________________________________________________________________
(Page 2 - NJCAA Eligibility Affidavit Continued)
5. Have you ever participated in practices, scrimmages, and/or games for an intercollegiate team other than this
college? Yes _____ No _____ If yes, name the school, date, sport, and describe the situation.
_____________
______________________________________________________________________________
______________________________________________________________________________
6. Have you ever played on a club team at a college or university? Yes _____ No _____ If yes, name the school, sport and dates.
_______________________________________________________________
______________________________________________________________________________
7. Do you currently play on any other sport teams (i.e. USAV, city recreational leagues, indoor soccer, AAU, etc.) Yes _____ No _____. If yes, please provide the name of team, location, and dates of participation.
_
_____________________________________________________________________________
8. Have you ever received money beyond expenses for participating in any athletic event? Yes _____ No _____ Did anyone on your team receive money beyond expenses for participating in any athletic event? Yes ____ No ____
If yes, describe the situation below and the NJCAA Amateurism Questionnaire should be completed and included
with the eligibility file. _
______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
List ALL Colleges Attended Full-Time and/or Part-Time after High School
All transcripts from all previous institutions must be included.College:
________________________
Dates:_____________________
Full-time or Part-time? (circle one) College:________________________
Dates:_____________________
Full-time or Part-time? (circle one) College:________________________
Dates:_____________________
Full-time or Part-time? (circle one) College:________________________
Dates:_____________________
Full-time or Part-time? (circle one)Additional Explanations:
NOTE: If you attended college part-time or were not attending college for any period of time following high school
graduation, please document your employment and military history during those times in the space below. If you were unemployed at any time, please list those dates below. The NJCAA requires that you account for any time not enrolled full-time. Please use the space below. Please record months and years when referring to dates.
_______________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
I understand that information falsified or omitted can make me ineligible for ALL future college competition in compliance with the National Junior College Athletic Association Eligibility Rules.C
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NA M E Co lle ge ID # _ ___ ___ __ __ ___ __ __ ___ ___ __ _ AG E D A TE O F B IR TH Last Firs t M idd le S ex ( M al e or Fem al e) : _____________ SPO R T (S) L O CA L A D DRE S S LO C A L TE LE P H O N E # S tr eet Ci ty S tate Zi p In case of an E m er genc y not if y N am e: P hon e N um ber :_ ______________ R el ati ons hi p : _ _______ _____ P E R S O N AL H E AL T H H IS T O R Y PL EA SE C O M PL E T E PR IO R T O EXAM IN AT IO N . C h ec k t h e appr o pr ia te ans w er f o r eac h que s ti o n. (Al l ques ti ons mu s t be ans w e red ) H a v e yo u ev er had : C ir cl e O n e C ir cl e O n e C ir cl e O n e A lle rg ie s: Ye s No B ladde r d ise a se Ye s No C onc us s ion Ye s No P e n icillin Ye s No D iabet es Ye s No H e a rt M u rm u r/D is eas e Ye s No S ul fa D ru gs Ye s No S ickle C e ll An e m ia Ye s No R heu m ati c F ev er Ye s No B ee S ti ngs Ye s No S c ar let F ev e r Ye s No Hi g h B lo od P res s ur e Ye s No A sp ir in Ye s No C hes t P ai n/P res s ur e Ye s No Lo w B lo od P re s s u re Ye s No O th er S hor tnes s of B re ath Ye s No M eas les (R e d ) Ye s No M um ps Ye s No C hi c k en P o x Ye s No M eas les ( G er m a n) Ye s No A nem ia Ye s No E pi leps y /S ei z ur e s Ye s No T ub er c ul os is Ye s No A s thm a Ye s No M onon uc leos is Ye s No E nl ar g ed S pl e en Ye s No R ec ur re nt H e ada c hes Ye s No H ead Inj u ry Ye s No He a t Re la ted Il lnes s Ye s No P neum oni a Ye s No wi th unc ons c ious nes s Ye s No N ec k /B ac k I nj ur y Ye s No K idne y p robl e m s Ye s No J oi nt I nj ur y /di s ea s e Ye s No S houl de r D islo ca tio n Ye s No C ont ac t Le ns es Ye s No D ent al appl ia nc e Ye s No S ur g er y : E ye G la sse s Ye s No B u lim ia Ye s No A ppen dec to m y Ye s No F em al es On ly: A re yo u tak in g m edi c a ti o n ( inc lude i nhal e rs ) T ons ill ec tom y Ye s No Ir regul a r pe ri ods Ye s No D ru g/D os e H er ni a R ep ai r Ye s No S ev er e Cr am ps Ye s No K nee S houl de r Ye s Ye s No No If you answ er ed “Y ES ” t o any of the a bove quest ions an d/ or have any f ur th er inf or m at ion, w hi ch i s know ledgeabl e to you and not
re qui red on t hi s for m , pl ease e xpl ai n i n det ai l bel ow (use addi tional sheet (s) if necessar y) - ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ _ __ ___ ___ __ ____ ___ _ __ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ _ __ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ __ _ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ __ ____ ___ ___ ___ _ _ ____ ___ ___ ___ _ I, the under signed, her eby acknow ledge, af firm , and r epr es ent that al l the abov e st at em ent s ar e t rue an d accur at e to t he bes t of m y know ledge; and t hat no answ er s or inf or m at ion have been wi thhel d. If any inf or m at ion and/ or st at em ent s ar e f als e and/ or hav e been o m itted in r ef er ence t o m y pas t and/ or pr esent m edi cal hi stor y, I acknow ledge that m y heal th and phys ical w elf ar e m ay be jeopar dized and ther ef or e hol d the Col leg e of S out her n M ar yla nd and i ts agent s bl am eles s f or any pr ev ious m edi cal condi tion I m ay have. Thi s physi cal is f or no ot her p ur pos e t han to cl ear m e f or at hlet ic par tic ipat ion at the Col lege of S out he rn M ar ylan d and I under stand i t is a requi rem ent in o rder for m e t o pr act ice, w or kout , or ot her wi se par tici pat e as a rost er ed m em ber of any Col lege of S out her n M ar yland ath let ic t ea m . A ll i nf or m at ion cont ained her ein i s pr ot ect ed unl ess w rit ten consent is given t o shar e sam e and onl y as i s r easonabl e and nec es sar y f or m y m edi cal car e.
S tudent -A thl ete S ignatur e Date P ar ent/ G uar di an S ignatur e Date IN SU R A N C E C O M PAN Y PO L IC Y# G R O U P # I s t hi s an H M O ? Y N N AM E O F PO L IC Y H O L D ER I N S AD D R E SS PH #
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M eas ur ement s an d V it al S igns : Hei g ht :____ _ ____ ____ W ei ght : ____ __ ____ ____ _ B lood P re s s ur e: _____ ___ _ ____ _ / ____ ____ ____ ___ P ul s e: ____ _ ____ ____ ___ __ P h y sical E x am (to be c o m p leted by the phy s ic ian) -N O R M A L A B N O R M A L F IN DI N G S H ea rt / C ar di ov as c ul a r Pu lm ona ry / Lung s A bdom e n / G as tr oi nt es ti n a l E y es , E ar s , N os e a nd T h ro at M us c ul o s k el e tal R ev iew O ther R ecom m endat ions / C om m ent s: Sta tu s : Clear ed wi thout r es tri cti ons Cl ear ed wi th re str ict ion s Not C lear ed/ Fur ther E val uati on N eeded - Phys ici an’ s S ignat ur e Phys ici an’ s A ddr es sPhys ici an’ s P rint ed Nam e Phys ici an’ s P hon e N um ber
Statement of Informed Consent, Assumption of Risk, and Release
Name Student ID #
By signing this statement, I express my desire to compete in intercollegiate athletics at the College of Southern Maryland, and acknowledge and affirm the following:
I understand that participation in intercollegiate athletics involves inherent risks of injury, and that the nature of the risks may vary depending upon the type of activity and my own physical condition and conduct. I also understand that it is not possible to specifically list each and every individual risk, but that most activities may involve risks associated with strenuous exercise, as well as risks from the use of equipment or participation in group activities. I acknowledge that I will either ask for or have been given any information that I need to determine the general risks associated with this activity.
I understand that I will complete a written self-evaluation of my health status and obtain a complete physical examination before participating in this activity, but that it is ultimately my responsibility to determine whether I can safely participate in this activity. I understand and agree that I will not be allowed to participate in any physical activities that are part of this activity until I have consulted my physician and obtained a physical examination.
I understand that certain precautions may be advised for the particular activity. I agree to follow those precautions and to conform to all rules and policies of the department, the coaching staff and any other sponsor of this activity. However, I recognize that these precautions will not eliminate the risks inherent in the activity.
I voluntarily assume all risks of loss, damage, illness, or injury which I may sustain while participating in this activity, including travel and usage of or any equipment or facilities. I will make no claim against and release, waive, discharge hold harmless and indemnify, on behalf of myself, my personal representative and my heirs, the College of Southern Maryland and its officers, agents and employees for any and all claims and causes of action for any injury or loss, or for damages, costs, expenses, or compensation that may occur during or result from my participation in this activity, whether arising through the negligence, omission, default, or other action of any person or event associated with this course or event, including fellow participants.
DATE SIGNATURE OF PARTICIPANT
If participant is under the age of 18, parent or guardian must complete the following:
I have read and understand the above information. I give my permission for my child to participate in this course/activity and grant the same informed consent, assumption of risk, and release on behalf of myself, my child and the child’s family.
DATE SIGNATURE OF PARENT OR GUARDIAN
College of Southern Maryland
College of Southern Maryland
Student Athlete Code of Conduct
PLEASE READ THE FOLLOWING MATERIAL CAREFULLY AND RETURN THE SIGNED FORM
Participation in College of Southern Maryland (CSM) intercollegiate athletics program is a privilege and not a right. For the purpose of this document, student athletes refers to any student who desires to participate as a player or other member, i.e. student worker, etc., of CSM’s intercollegiate athletic team program. Student team members agree to certain responsibilities. The college places expectations on team members and reserves the right to limit participation based on academic standing and/ornoncompliance with NJCAA/Region XX/JUCO rules and regulations and or/CSM policies and procedures.
Student Athlete Responsibilities
1. I completely read and understand all College policies as outlined in the current annual catalog, including:
a. Student Conduct Code c. Student Rights and Responsibilities b. Sexual Harassment Policy d. Drug and Alcohol Policy
2. I understand that any violation of the above policies may be grounds for dismissal from athletic participation as well as from the college. Acts of misconduct include, but are not limited to:
a. Illegal or unauthorized use, possession, manufacturing or dissemination of alcohol, or public intoxication.
b. Use, possession, manufacturing, or dissemination of marijuana, heroin, narcotics, or other controlled substances (as defined by Maryland or federal law) except as expressly permitted by law.
c. Use of tobacco and tobacco products (smoking) is prohibited.
d. Unauthorized use, manufacture, distribution or possession of weapons, ammunition, fireworks, explosives, dangerous chemicals and/or firearms.
e. Engaging in any form of forcible or “non forcible” sexual misconduct.
3. I understand that athletes ejected from a contest for any reason will not be allowed to participate in the next regularly scheduled contest in that sport, and must leave the venue at that time. If the ejection reason was due to violent conduct, the athlete would be removed from the venue and would not be allowed to participate in the next two regularly scheduled contests.
a. In incidents of ejection, the Athletic Director/and or Assistant Director will meet with the individual(s) and the head coach to review CSM’s commitment to proper
sportsmanship.
b. A second offense for a violent ejection will not be tolerated, and after review of the incident could be grounds for dismissal from the team.
c. CSM shall review each incident and determine if additional internal sanctions will be placed upon the individual(s) involved.
4. I understand CSM teams must finish the regular season with a minimum of a .500 winning percentage overall, against divisional opponents, or against teams in MD JUCO in order to participate in post-season play.
5. I have provided accurate and complete information on all the requested forms.
6. I have not been instructed to provide inaccurate or incomplete information on this form by any CSM staff member.
7. I give the College of Southern Maryland permission to release my official and unofficial transcript and academic progress to the athletic department with the intent to determine athletic eligibility and awards.
8. I understand that my participation in any fraction of a single contest constitutes a year of eligibility used, including participation on a club team.
9. I understand that I must be enrolled in at least 12 credit hours during the entire length of my intercollegiate athletic season, and remain in those 12 credits for the whole semester to be eligible to receive my performance award. If I do not follow the above, I will become immediately ineligible. Additionally, my team will be forced to forfeit any games that I participated in while enrolled in less than 12 credit hours. Please Note: enrollment does not include audited classes.
10. I understand that I will follow and abide by all the rules for the College of Southern Maryland’s Athletic Academic Policy.
11. I give the College of Southern Maryland permission to include me on a roster listed on the College of Southern Maryland and NJCAA website. I also give permission for my athletic accomplishments and photo to be listed as well.
12. Conference by-laws prohibit athletes from publicly criticizing game officials, referees or coaches to the media or on the internet. I understand that my participation as an athlete may be terminated if I violate this requirement.
13. I agree to pay any and all applicable fees for missing or damaged (less normal wear) CSM issued team uniforms, practice uniforms and/or equipment that is not returned to the Athletic
Coordinator at the end of the season.
14. I understand that prior to athletic participation I must have completed all the necessary forms and received a physical examination from a licensed physician.
15. I understand that the use of profanity is prohibited in all competitions and practices, as well as, in CSM functions, study halls and all classroom settings.
With my signature below I agree, acknowledge, and accept the responsibilities stated
above and understand that the College of Southern Maryland reserves the right to
remove me from any and all participation in the intercollegiate athletic team program.
____________________________________ _________ ___________________________
(Athlete’s Printed Name) (Date) (Sport)
____________________________________ __________________________________________
(Athlete’s Signature) (Parent/Guardian’s Signature, required if athlete is