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GOPHER CHEERLEADING Try-out Packet 2019-2020

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2019-2020

TRYOUT PACKET University of Minnesota

CHEER (All-Girl, Co-ed, Small Co-ed)

FRESHMEN TRYOUT CLINICS: DATE TIME EVENT LOCATION Sunday, March 10th 9:00-4:00pm Freshmen Tryout Clinic Armory 15 Church St SE, Minneapolis, MN

SPRING TRYOUT CLINICS: DATE TIME EVENT LOCATION

Thursday, April 11th 5pm Registration/Paperwork Maturi Pavilion

6pm-9pm Fight Songs/Sideline 1925 University Ave SE, Minneapolis, MN

Tryout Clinic

Friday, April 12th 5:30pm Registration TBD

6pm-9pm Review Material, Stunt

Sideline and Rouser Tryout

Saturday, April 13th 8:30am Registration TBD

9am-12pm Tryouts

(All material except Rouser and Sideline)

6pm Posting for Call Backs

Sunday, April 14st 9:00-11:00am Twins (LEAD) Training Maturi Pavilion 11:00-1:30pm Twins Training 2:30-5:00 Team Meetings/Paperwork 3:30-4:30 Parent Meeting

It is important that you read and fully understand the enclosed

information. Give serious thought to the level of commitment you

must make if you are chosen to be part of this program.

If you have any questions or concerns, please do not hesitate to call

the University of Minnesota Spirit Squad Office at 612-624-7367.

Thank you for your interest and GOOD LUCK.

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Letter from the Head Coach

Dear Spirit Squad Prospect:

Becoming an athlete in the Spirit Squad program, at the University of Minnesota, means becoming part of a rich

tradition and a legacy that started over 100 years ago. Cheerleading was invented in 1898 on the University of

Minnesota campus, and our founder’s spirit and pride continue today. Very few people have had the privilege of

participating in America’s ORIGINAL cheerleading program.

Within the last decade, our teams have had a variety of notable accomplishments. Goldy Gopher has won 4

Mascot National Championships, finished top 5 for the last 15 years, and twice named NCAA/ESPN Mascot of

the year. The Hockey Cheer Team is comprised of talented figure skaters and has been recognized on ESPN,

BTN, Sports Illustrated, USFS Skating Magazine and is among the top Hockey Cheerleading teams in the

country. The Co-ed Cheer Team has consistently placed among the top 10 teams in the country in one of the

most competitive divisions at UCA College Cheer Nationals and finished 2nd place in Game Day in 2018.

Additionally, the U of M’s All-Girl Cheer Team, over the last 10 years, has finished top 5 four times in the most

competitive division at UCA College Cheer Nationals and finished 2nd place in Game Day in 2019. The Dance

Team has won 19 National Championships and is by far the winningest athletic team on the U of M campus,

winning 11 Jazz titles and 8 Pom titles.

Along with this great history comes a very serious sense of responsibility. As a Spirit Squad athlete you are a

representative not only of the athletic teams and department you support at this University, but also the entire

State of Minnesota. You are the most visible ambassadors we have, and it is expected that you conduct yourself

accordingly on and off the playing field.

The Spirit Squad is comprised of 6 teams and over 100 dedicated student-athletes who devote 15-20 hours

weekly to practices, games, special appearances, camps/clinics, fundraising events, and competitions. Spirit

Squad athletes are also expected to maintain high academic standards and carry a full credit load. Because of

these responsibilities, we are looking for skilled and talented athletes, and well-rounded students, who embrace

the ability to be coached, as well as find a healthy balance between athletics, school, family, and friends.

Our athletes come from across the country and many from diverse backgrounds in dance, cheerleading,

gymnastics, and skating. The common-ground amongst all of our program athletes is their dedication and

commitment to this program. Our athletes believe that improving as individuals, helps their team improve as

well.

We are excited for your interest and believe that the rewards from this experience cannot be measured. Imagine

the excitement that comes with being part of a Big Ten athletic department, performing at some of the biggest,

nationally televised games, traveling to storied venues around the country, and competing against some of the

top cheerleading and dance programs in the nation. Every once in a while you come across an opportunity and

make a decision that will change your life, securing friends for a lifetime and your place in history forever.

Sincerely,

Coach Owens, Head Spirit Squad Coach

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DESCRIPTION/COMMITMENT ALL-GIRL CHEER TEAM

The All Girl Cheer Team consists of all female cheerleaders who cheer for football and women’s basketball

games with an opportunity to travel to away football games and basketball tournaments. Athletes also perform

at a variety of off-campus appearances and they participate in all Spirit Squad fundraisers. The team has a year-

long time-commitment beginning each season at tryouts. All Girl Cheer Team annually commits to training for

the UCA National Competition (in January). All-Girl and Co-ed Cheer Team members are awarded an allotment for

books each semester. CO-ED CHEER TEAM

The Co-ed Cheer Team consists of men and women who cheer for football and men’s basketball games with an

opportunity to travel to away football and basketball tournaments. Athletes also perform at a variety of off-

campus appearances and they participate in all Spirit Squad fundraisers. The team has a year-long time-

commitment beginning each season at tryouts. Co-ed Cheer Team annually commits to training for the UCA

National Competition (in January). All-Girl and Co-ed Cheer Team members are awarded an allotment for books each

semester.

SMALL CO-ED CHEER TEAM

The Small Co-ed Cheer Team consists of men and women who cheer for football and women’s basketball

games. The Small Co-ed Cheer Team is a team designed for skill development. Athletes also perform at a

variety of off-campus appearances and they participate in all Spirit Squad fundraisers.

AG Practice Schedule

Summer (Exact dates and times TBA)

Twins Games (VETS): March 30, 31, April 28, June 14, 15, 16, Sept. 22

Twins Games (ROOKIES): Aug. 23, 24, 25, Sept. 6, 7, 8, 21

Mandatory Practices: May 16-19, June 25-30, July 25-31, and Aug. 14-29

Mandatory Spirit Squad Retreat: July 12-14, 2019

UCA College Camp: July 31st-Aug. 4th

All Girl Report Date: Aug. 14

Pride & Spirit: August 28

Co-ed Practice Schedule

Summer (Exact dates and times TBA)

Twins Games: Aug. 23, 24, 25, Sept. 6, 7, 8, 21

Mandatory Practices: May 16-19, June 25-30, July 25-31, and Aug. 14-29

Mandatory Spirit Squad Retreat: July 12-14, 2019

UCA College Camp: July 31st-Aug. 4th

Co-ed Report Date: Aug. 14

Pride & Spirit: August 28

Smoed Practice Schedule

Summer (Exact dates and times TBA)

Twins Games: Aug. 2, 3, 4, 9, 10, 11, Sept. 20

Mandatory Practices: July 10-11, Aug. 5-8, 18-29

Mandatory Spirit Squad Retreat: July 12-14, 2019

Smoed Report Date: Aug. 18

Pride & Spirit: August 28

School Year Practice Schedule – All Girl, Coed, Smoed (Exact dates and times TBA)

**YOU MUST SCHEDULE CLASSES AROUND PRACTICES, CONDITIONING, AND GAMES

Fall Semester Tues/Thurs evenings, additional Friday/Weekend practices TBD

Spring Semester Tues/Thurs evening Open Gym

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Special Events/Appearances Each Spirit Squad athlete is required to attend additional Athletic Department appearances.

When preparing for Nationals, there will be additional practices including some 2/day practices during

University breaks.

Team activities do not stop during Holiday Breaks/Spring Break.

Expenses for both teams: (team members are able to keep whatever items they are required to purchase)

Women: Team fee $350 (may include bodysuits, briefs, poms, outdoor attire that cannot be returned)

Men: Team fee $350 (may include outdoor attire, and other items that cannot be returned)

Check is due at the first practice, separate from the $50 tryout fee.

In the event you choose not to honor your commitment and finish the season or you are dismissed from the

program, you will be required to reimburse the U of M for the payments that have been made on your behalf.

CHEER TRYOUT REQUIREMENTS ELIGIBILITY: Spring tryouts are open to individuals who have been accepted by the University of Minnesota, Twin Cities for Fall Semester 2019.

All participants, including transfer students and current team members, must have a minimum 2.0 GPA and have graduated from high

school. Incoming students must bring a copy of their letter of acceptance on the first day of tryouts. Current U of M students must

bring an unofficial transcript.

TRYOUT PROCESS: Throughout the week of clinics and the final tryout you will be observed by the U of M Coaching Staff as well as a selection

committee. There may be a tryout cut at any time during the clinics. At the final tryout, you will be asked to individually perform

specific skills; however, there is not a point system. The final decisions are made by the coaching staff and/or a tryout selection

committee.

SKILLS: You will be asked to execute the skills listed below for tryouts. If you haven’t mastered all skills, do not be discouraged. We are not

necessarily looking for perfection at this time, but we do want you to concentrate and perfect the skills that play to your strengths. In

addition to the skills listed, you will be observed throughout the tryout clinics on your attitude, ability to learn and make changes,

enthusiasm, projection and overall performance. We will be looking for current and potential skills to become a collegiate

cheerleader. (NOTE: requirements are subject to change; you will be informed of any changes at the first day of clinics.)

TRYOUT MATERIAL AND REQUIREMENTS:

Interview with coaches

Fight Song - Minnesota Rouser

Fight Song- Minnesota Fight

A Sideline Cheer

Tumbling:

o Standing: Handspring, Tuck, BHS-Tuck, BHS/BHS-Full

o Pass: Round-off followed by three consecutive skills

All-Girl Partner Stunts:

o Full up stunt

o Single-base extension or Liberty

o Elite partner stunt sequence including a flipping stunt or inversion with a full down or double full down

Co-ed Partner Stunts:

o Stunt 1: Toss extension/ lib, bonus for full up

o Stunt 2: Round off/backhand spring up, hand to hand, or rewind, bonus – high to high at the end

o Elite partner stunt sequence (suggested: 1-Arm stunt or flipping stunt, may link skills together)

We would like to see one of your chosen stunts end in a heel stretch body position.

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UNIVERSITY OF MINNESOTA INFORMATION

FIGHT SONG: “THE MINNESOTA ROUSER”: The University's main fight song was written in 1909 by Floyd M. Hutsell for a contest sponsored by the Minneapolis Tribune. The Minnesota cheer Ski-U-Mah, pronounced sky-you-ma, is more than 100 years old: the word "ski" (which, according to legend, was an American Indian victory cry), and "U-Mah" (represents "University of Minnesota") were created by two rugby players as an easy-to-remember team cheer. The phrase stuck and was incorporated into the "Minnesota Rouser.":

Min-ne-so-ta, hats off to thee! To our colors true we shall ever be.

Firm and strong united are we!

Rah Rah Rah for Ski U Mah

Rah Rah Rah Rah

Rah for the U of M

(repeat)

M - I - N - N - E - S - O - T - A!

Minnesota!

Minnesota!

Yeaaaaaaah Gophers!

FIGHT SONG: “MINNESOTA FIGHT”

“Minnesota Fight” is one of several school songs of the University of Minnesota. It was written by a University

graduate, Truman E. Rickhard, in response to a contest to find an additional fight song for the school. The piece

was originally entitled “Minnesota! Let’s Go!” but is now known as “Minnesota Fight.” “Minnesota Fight” has

stood the test of time and continues to be performed regularly by the Minnesota Band. Minnesota, come on, let’s go!

It’s a loyal crowd that’s here;

With a Sis-Boom-Ah and a Ski-U-Mah,

For the varsity we cheer! Rah! Rah!

The old fight gang, on your marks, Slam! Bang!

Hit ‘em hard and hit ‘em low,

So fight, Minnesota, fight!

Minnesota! Come on, let’s go!

ALMA MATER: “HAIL MINNESOTA” "Hail! Minnesota" was written in 1904 by Truman Rickard for a class play. The song was performed again at

commencement that year and continued to gain in popularity. It eventually became the school song, and in 1945

it became the official song of the state of Minnesota: Minnesota, Hail to thee!

Hail to thee our college dear!

Thy light shall ever be

a beacon bright and clear.

Thy sons and daughters true

will proclaim thee near and far.

They will guard thy fame, and adore thy name;

Thou shalt be their Northern Star!

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2019-2020 Gopher Football Schedule

AUG 29 (THU) TBA VS SOUTH DAKOTA STATE TCF BANK STADIUM

SEP 7 (SAT) TBA AT FRESNO STATE FRESNO, CA

SEP 14 (SAT) TBA VS GEORGIA SOUTHERN UNIVERSITY TCF BANK STADIUM

SEP 28 (SAT) TBA AT PURDUE UNIVERSITY WEST LAFAYETTE, IN

OCT 5 (SAT) TBA VS UNIVERSITY OF ILLINOIS TCF BANK STADIUM

OCT 12 (SAT) TBA VS UNIVERSITY OF NEBRASKA TCF BANK STADIUM

OCT 19 (SAT) TBA AT RUTGERS UNIVERSITY PISCATAWAY, NJ

OCT 26 (SAT) TBA VS UNIVERSITY OF MARYLAND TCF BANK STADIUM

NOV 9 (SAT) TBA VS PENN STATE UNIVERSITY TCF BANK STADIUM

NOV 16 (SAT) TBA AT UNIVERSITY OF IOWA IOWA CITY, IA

NOV 23 (SAT) TBA AT NORTHWESTERN UNIVERSITY EVANSTON, IL

NOV 30 (SAT) TBA VS UNIVERSITY OF WISCONSIN TCF BANK STADIUM

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2019-2020 Spirit Squad Application

Please place an “X” next to the team you wish to try out for, or

rank the teams if you are interested in more than one:

All Girl Cheer Team

Co-Ed Cheer Team

Small Coed Cheer Team _______

PERSONAL INFORMATION:

Name: (First) (Last) (Middle)

Cell Phone:

Email address:

Parents Name(s):

(First) (Last) / (First) (Last)

Parent # 1Address:

(Street)

(City) (State) (Zip Code)

Parent #1 Phone:

Parent # 2 Name: (If different from above) (First) (Last)

Parent # 2 Address:

(If different from above) (Street)

(City) (State) (Zip Code)

Parent #2 Phone:

SCHOOL INFORMATION Year in College for the 2019-2020 School year:

Fr So Jr Sr 5th Year Major:

U of M Student ID Number:

Date of Birth:

In reviewing the summer time commitment, will you have any conflicts over the summer? If so, please explain.

Are you currently employed? If yes, where?

Will you be working while you are in school?

If yes, how many hours per week?

Please attach

current photo

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APPLICATION CHECKLIST The following is a checklist to help ensure you are prepared for tryouts. Please follow these instructions carefully

and bring your completed packet/application with you to tryouts.

IT IS ESSENTIAL THAT YOU HAVE ALL ITEMS ON THIS LIST

TO TURN IN AT REGISTRATION. You will not be able to

participate in any portion of the tryout process without complete

forms (including any missing information on the forms) - this includes

veteran/returning members.

1. Application/ Picture (attached -- packet page 8)

a. All applicants must complete form.

b. Please attach a current photo.

2. Try-out Fee: $50 cash or check made out to University of Minnesota

3. Waiver Form (attached)

a. All applicants must complete and sign the Waiver Form – no substitutions.

b. If you are under the age of 18, you must have a guardian’s signature.

4. Demographic/Insurance Form (attached)

a. All applicants must complete both pages of the Medical Insurance Form.

b. Attached to this form, all applicants must provide a photocopy of the front and back of

your medical insurance card.

c. Be sure to complete the form in full – i.e. Policy Holder Information, DOB, etc. and it must

be signed.

d. Must complete the U of M Insurance Form – no substitutions will be accepted.

5. Pre-Participation Physical/Heath History Form (attached)

a. New candidates only.

b. Must be completed within the past 6 months (from tryout date).

c. Must indicated or be marked “Cleared” for participation.

d. If applicant is under the age of 18, it must co-signed by a guardian.

6. Sickle Cell Trait Testing Waiver (attached)

a. New candidates only.

7. Health Service To Minors Form (attached)

a. New candidates (under age 18) only.

8. Proof of Admission

a. Copy of acceptance letter for incoming freshmen/transfer students

b. Unofficial copy of transcript for current University of Minnesota students

c. New candidates only.

UNIVERSITY OF MINNESOTA ATHLETIC MEDICINE TRY OUT WAIVER

To be eligible to participate in an Intercollegiate Athletics Try-Out participants must:

Provide medical documentation of an athletic pre-participation history & physical, signed by a medical doctor (either an MD or a DO) and dated within six months of the start of this team tryout.

Provide confirmation of sickle cell trait (SCT) status, either through: 1) existing documentation from birth, or; 2) recent screening. Or the student may sign a waiver declining confirmation of SCT status if he or she is first provided education by the institution regarding the implications of exercising the waiver option.

Complete the Demographic and Insurance Information sheet and provide proof of current medical insurance with a copy of the front and back of current insurance card. If participant makes the spirit squad team, usable insurance in the state of Minnesota (which covers athletic-related and specifically cheer-related injuries) will be required prior to starting any team related activity.

I acknowledge my voluntary participation in practice activities associated with the SPIRIT SQUADS at the University of Minnesota. This try-out will extend no longer than 4 days.

I understand that while I am participating in intercollegiate athletics there is a risk of injury. I understand that such an injury can range from a minor injury to a major injury. Such injuries could cause permanent disability such as paralysis, permanent bone or joint injury, permanent scars, other chronic disabling conditions and even death.

I hereby waive any and all claims, causes of action, rights to entitlements, suits or damages against the University of Minnesota, the Intercollegiate Athletic Department, or any of its employees, agents or representatives, as a result of or occurring in conjunction with, my participation during this try-out. I also waive any and all claims to any other services, uniforms, equipment, medical or training services, academic services, tutoring, computers and the like.

I verify that I have no physical disabilities, impairments or chemical dependencies that inhibit my participation in sport activities. I do not know of any medical reason why I should not participate in a try-out for my sport. I hereby accept and assume the risk of injury and understand the possible consequences of such injury.

I, the undersigned, have read this form carefully and understand all its items.

Participant Signature Date

Printed Name of Participant Date of Birth

Student ID Number

Parent/Guardian Signature (if a minor) Date

MDN 3-23-16

Office Use Only: Medical Record Number:

2018-2019

Master EMR

UNIVERSITY OF MINNESOTA ATHLETIC MEDICINE Demographic/Insurance Information

Student-Athlete’s Name M or F

Circle one

Date of Birth

Student ID Sport

Please use black ink only. Provide all information to avoid a delay in participation.

Ca

mp

us

Campus Mailing Address

Cell Phone # ( )

UMN Email address @umn.edu

Em

erg

en

cy

Co

nta

ct

Emergency Contact Name

Relationship to Student-Athlete

Street Address, City, State, Zip

Phone Numbers/ Email address

Telephone ( )

Cell Phone ( )

Email Address

Pri

ma

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nsu

ran

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My son/daughter will NOT have medical insurance and will therefore be purchasing the Student Health Benefit Plan

My son/daughter will be covered under the following health plan (please provide the following information):

Insurance Company ID Number Group Number

Insurance Company Mailing Address

Phone Number ( )

Effective Date Deductible Amount

Subscriber Name Subscriber Date of Birth Subscriber Employer

Health Savings Account Yes No

HSA Acct Number Owner’s Name HSA Amount

Se

co

nd

ary

Ins

ura

nce

Insurance Company ID Number Group Number

Mailing Address

Phone Numbers ( )

Effective Date Deductible Amount

Subscriber Name Subscriber Date of Birth Subscriber Employer

Ph

arm

ac

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ns

ura

nc

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Company Name

Den

tal

Ins

ura

nce

Company Name

ID Number

ID Number Group Number

BIN # PCN Mailing Address

Group Number City, State and Zip

Phone Number ( )

Phone Number ( )

Page 2 of 3

Pri

ma

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are

/

Ne

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Please provide contact information for your Primary Care Provider (PCP). Also review the health plan policy regarding HMOs/PPOs and the options for changing your primary clinic.

PCP Name

Address City, State, Zip Phone Number ( )

The primary insurance plan is a HMO or PPO policy If the insurance plan is a PPO policy, please provide the name of the network that can be used in Minnesota:

Copies of medical, dental and pharmacy insurance cards (front and back)

I certify that the above information is true and correct. If incorrect or incomplete information is given, I may be responsible for all charges. I understand that I am responsible for payment of all charges incurred for claims classified as “non-athletic”. I understand that I must forward changes of insurance and information to the Athletic Medicine Department as they occur through the year.

By signing below, I grant the Insurance Coordinator in Intercollegiate Athletics at the University of Minnesota, access to my medical records and insurance information in order to coordinate benefits, make inquiries and make payments on my behalf. This permission is granted for one year and may be revoked, in writing, at any time.

Policy Holder’s Signature Date Student-Athlete Signature Date

Office Use Only: Medical Record Number:

2018-2019

Master EMR

UNIVERSITY OF MINNESOTA ATHLETIC MEDICINE

Sickle Cell Trait Testing Waiver

Patient label

About Sickle Cell Trait

Sickle cell trait is an inherited condition of the oxygen-carrying protein, hemoglobin, in the red blood cells.

Sickle cell trait affects approximately 1% of the U.S. population (approximately 1 in 100 individuals).

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.

Sickle cell trait is usually benign, but during intense, sustained exercise, hypoxia (lack of oxygen) in the muscles may cause sickling of the red blood cells (red blood cells changing from a normal disc shape to a crescent or “sickle” shape), which can accumulate in the bloodstream and “logjam” blood vessels, leading to collapse from the rapid breakdown of muscles starved of blood.

Sickle Cell Trait Testing The NCAA mandates that medical examinations for athletic participation include sickle cell trait testing to ensure that all NCAA student-

athletes have knowledge of their sickle cell trait status before the student-athlete participates in any intercollegiate athletics event, including strength and conditioning sessions, practices, competitions, etc. Sickle cell trait testing is not required by NCAA when a student-athlete provides documented prior results to the institution or knowingly and voluntarily declines testing and signs a written release.

The University of Minnesota Department of Intercollegiate Athletics offers sickle cell trait screening in the form of a blood test to all student-athletes as part of the pre-participation physical examination process.

Testing will be conducted at the University of Minnesota Physicians Laboratory and the results will be reported to a University of Minnesota Team Physician.

SICKLE CELL TRAIT TESTING WAIVER I, __________________________________, understand and acknowledge that the NCAA and the University of Minnesota Department of Intercollegiate Athletics require medical examinations that include sickle cell trait testing so that all student-athletes have knowledge of their sickle cell trait status. Additionally, I have read and fully understand the aforementioned facts about sickle cell trait and 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 University of Minnesota the Athletic Medicine staff.

Understanding the risks of sickle cell trait and athletic participation, I do not wish to undergo sickle cell trait testing as part of my pre-participation physical examination, and I voluntarily agree to release, discharge, indemnify and hold harmless the Regents of the University of Minnesota, its officers, employees and agents from any and all costs, liabilities, expenses, claims, demands, or causes of action on account of any loss or personal injury that might result from my declining sickle cell trait testing.

I have read and signed this document with full knowledge of its significance. I further state that I am at least 18 years of age and competent to sign this waiver.

Student-Athlete Signature Date Sport

Student-Athlete Print Name UM ID#

Parent / Guardian Signature (if under 18 years of age)

Date

Witness Date

UM Athletic Medicine / OGC June 2013

UNIVERSITY OF MINNESOTA ATHLETIC MEDICINE

Health Services To Minors

University of Minnesota Athletic Medicine complies with the laws of the State of Minnesota when providing health

services to minors (persons under age 18). Under the following circumstances you may give consent for yourself to

receive medical, dental, mental, or other health services:

If you are emancipated, i.e., living away from parents or legal guardian and managing your own finances,

regardless of income source;

If you are married or have given birth to a child; or

If you require services relative to pregnancy, sexually transmitted disease, or chemical dependency.

Minors, not meeting the above criteria, need to have parental/guardian authorization for health services except when

emergency care is required, i.e., the risk to life or health is of such a nature that treatment should be given without

delay, and the requirement of consent would result in delay or denial of treatment.

By giving your consent for any of the foregoing medical, dental, mental, or other health services, you assume financial

responsibility for the cost of these services.

University of Minnesota Athletic Medicine staff may inform you parents or legal guardian of treatment provided or

care needed where, in the professional's judgment, failure to inform your parents or guardian would seriously

jeopardize your health.

PARENTAL/GUARDIAN AUTHORIZATION FOR TREATMENT OF MINORS (Persons under age 18)

I authorize that in the event of an illness or injury, medical or hospital care by provided to

Participant’s Name (please print) Date of Birth

I further authorize each of the following:

A. I grant permission to the University of Minnesota Athletic Medicine staff member to employ such diagnostic

procedures and medical treatment as deemed necessary.

B. I authorize the University of Minnesota Athletic Medicine Staff, University of Minnesota Physicians Clinics,

Hospital or other medical care units to release medical records information to the appropriate health insurance carrier in

order to process claims.

I understand that I am financially responsible for charges not covered or paid by student fees or insurance and hereby

guarantee full payment to the physicians or health care units.

Participant’s Signature Date Team

Participant’s Print Name UM ID#

Parent / Guardian Signature (if under 18 years of age)

Date

Parent / Guardian Print Name Date Witness Date