CS 314937A 04/15/2020

cdc.gov/coronavirus

What you should know about COVID-19 to protect yourself and others

Know about COVID-19• Coronavirus (COVID-19) is an illness caused

by a virus that can spread from personto person.

• The virus that causes COVID-19 is a newcoronavirus that has spread throughoutthe world.

• COVID-19 symptoms can range from mild(or no symptoms) to severe illness.

Know how COVID-19 is spread• You can become infected by coming into

close contact (about 6 feet or twoarm lengths) with a person who hasCOVID-19. COVID-19 is primarily spreadfrom person to person.

• You can become infected from respiratorydroplets when an infected person coughs,sneezes, or talks.

• You may also be able to get it by touching asurface or object that has the virus on it, andthen by touching your mouth, nose, or eyes.

Protect yourself and others from COVID-19• There is currently no vaccine to protect

against COVID-19. The best way to protectyourself is to avoid being exposed to thevirus that causes COVID-19.

• Stay home as much as possible and avoidclose contact with others.

• Wear a cloth face covering that covers yournose and mouth in public settings.

• Clean and disinfect frequentlytouched surfaces.

• Wash your hands often with soap and waterfor at least 20 seconds, or use an alcohol-based hand sanitizer that contains at least60% alcohol.

milk Practice social distancing• Buy groceries and medicine,

go to the doctor, andcomplete banking activitiesonline when possible.

• If you must go in person,stay at least 6 feet away fromothers and disinfect items youmust touch.

• Get deliveries and takeout,and limit in-person contact asmuch as possible.

Prevent the spread of COVID-19 if you are sick• Stay home if you are sick,

except to get medical care.

• Avoid public transportation,ride-sharing, or taxis.

• Separate yourself from otherpeople and pets in your home.

• There is no specific treatmentfor COVID-19, but you can seekmedical care to help relieveyour symptoms.

• If you need medical attention,call ahead.

Know your risk for severe illness• Everyone is at risk of

getting COVID-19.

• Older adults and people ofany age who have seriousunderlying medical conditionsmay be at higher risk for moresevere illness.

Colorado School of Mines Athletics Forms Check List

Returning Student-Athletes SHBP

2020-21

COVID-19 UPDDATE: We are currently formulating a plan to maintain the health and well-being of all of our student-athletes, coaches and staff. As soon as we have an approved plan, that information will be made available to you.

Welcome back to Colorado School of Mines Athletics! The following are instructions for completing the necessary medical and insurance forms to allow you to participate in varsity athletics.

Please type directly in all pdf forms (hand written forms will not be accepted), print all forms and sign where required – including parent / guardian signatures.

All forms must be emailed to your Athletic Trainer by August 1, 2020 (NO MAILED IN FORMA WILL BE ACCEPTED)

1. Medical History Questionnaire2. Acknowledgement of Risk3. Injury & Illness Reporting Policy4. Sickle Cell Trait Testing & Waiver5. Signature on the Concussion Fact Sheet6. Acknowledgement of Insurance Requirements

SHBPYou must complete the CSM Student Health Benefit Plan, SHBP, Enrollment/Waiver process on Trailhead to confirm your participation in the plan.

For questions, please contact: Jennifer McIntosh 303-273-3375 jdwyer@mines.edu Andy VanousJacob Pope Jessica Newman Meghan Powell

303-273-3575 avanous@mines.edu 303-384-2084 jpope@mines.edu 303-384-2556 jhoyt@mines.edu 303-273-3078 mtpowell@mines.edu

Remember, we must receive all documents before you will be cleared to report to your respective sport including team meetings, tryouts, practices or competitions.

Please type directly in all pdf forms (hand written forms will not be accepted), print all forms and sign where required – including parent / guardian signatures.

All forms must be emailed to your Athletic Trainer by August 1st, 2020 NO MAILED IN FORMS)

Colorado School of Mines- Athletic Training Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Explanation of Forms. Colorado School of Mines- Athletic Training handles medical information about you, and law regulates how that information is handled. To comply with the law, Colorado School of Mines- Athletic Training asks you to receive this notice and, in some circumstances, to sign an authorization form.

Colorado School of Mines- Athletic Training is allowed by law to use and disclose information about you for the purposes essential to providing care (treatment, payment collection, and operating Colorado School of Mines- Athletic Training).

An authorization allows Colorado School of Mines- Athletic Training to use and disclose information about you for any other reason that is indicated by you in the authorization. Colorado School of Mines- Athletic Training may not refuse to treat you for refusing to sign the authorization. Other rules about your rights regarding medical information are described in this notice.

Types of Uses and Disclosures. Medical information about you may be used or disclosed by Colorado School of Mines- Athletic Training for treatment, payment, and health care operations. Treatment includes consultation, diagnosis, provision of care, and referrals. Payment includes all those things necessary for billing and collection, such as claims processing. Health care operations include things Colorado School of Mines- Athletic Training does to assess quality of care, train staff, and manage Colorado School of Mines- Athletic Training business. Some examples of disclosures and use are as follows:

• Example of Treatment Disclosure. Colorado School of Mines- Athletic Training may disclose medical information about you to your treating physician,a hospital or other providers to help them diagnose and treat an injury or illness.

• Example of Payment Disclosure. Colorado School of Mines- Athletic Training may disclose medical information about you when health plans orinsurers, Medicare, Medicaid, or other payors require the information before paying for your health care services.

• Example of Health Care Operations Use. Colorado School of Mines- Athletic Training may use medical information about you when it hires new staffwhose training requires information about the medical needs of our patients.

Colorado School of Mines- Athletic Training may also contact you to provide appointment reminders or cancellations or to notify you of follow up tests or procedures that may be required. We may leave this limited information on an answering machine or voicemail at the numbers provided by you unless you request a restriction regarding this method of communicating your protected health information.

Other Uses and Disclosures. We may use or disclose your protected health information in the following situations without your authorization. These situations include:

• As Required By Law. We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use ordisclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.

• Public Health. We may disclose your protected health information for public health activities and purposes to a public health authority that is permittedby law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may alsodisclose your protected health information to another government agency that is collaborating with the public health authority.

• Communicable Diseases. We may disclose your protected health information, if authorized by law, to a person who may have been exposed to acommunicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

• Health Oversight. We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits,investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system,government benefit programs, other government regulatory programs and civil rights laws.

• Abuse or Neglect. We may disclose your protected health information to a public health authority that is authorized by law to receive reports of childabuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect ordomestic violence to the governmental entity or agency authorized to receive such information.

• Food and Drug Administration. Colorado School of Mines- Athletic Training may disclose a patient’s health information to a person subject to thejurisdiction of the Food and Drug Administration if that person has responsibility to report adverse events, product defects or problems, or biologicproduct deviations; to track products; to enable product recalls, repairs or replacements; or, to conduct post marketing surveillance.

• Legal Proceedings. We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order ofa court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discoveryrequest or other lawful process.

• Law Enforcement. We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcementpurposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests foridentification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in theevent that a crime occurs on the premises of Colorado School of Mines- Athletic Training, and (6) medical emergency (not on Colorado School ofMines- Athletic Training premises) and it is likely that a crime has occurred.

• Coroners, Funeral Directors, and Organ Donation. We may disclose protected health information to a coroner or medical examiner for identificationpurposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also discloseprotected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out his duties. We may disclosesuch information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissuedonation purposes.

• Research. We may disclose your protected health information to researchers when the research has been approved by an institutional review boardthat has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

• Criminal Activity. Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use ordisclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public

• Military Activity and National Security. When the appropriate conditions apply, we may use or disclose protected health information of individuals whoare Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determinationby the Department of Veterans Affairs of eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services.We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities,including for the provision of protective services to the President or others legally authorized.

• Workers’ Compensation. Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws andother similar legally established programs.

• Inmates. We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created orreceived your protected health information in the course of providing care to you.

• Required Uses and Disclosures. Under the law, we must make disclosures to you and when required by the Secretary of the Department of Healthand Human Services to investigate or determine our compliance with the law.

Others Involved in Your Healthcare. Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

Authorized Uses and Disclosures. Additional uses and disclosure may be made if you have given written authorization, which may be revoked at any time in writing delivered to the Director, except to the extent Colorado School of Mines- Athletic Training acted in reliance on the authorization.

Restrictions. You have the right to request restrictions on the use and disclosure of medical information about you; however, Colorado School of Mines- Athletic Training will only be bound by the restrictions if Colorado School of Mines- Athletic Training notifies you that it agrees with them.

Confidentiality. You have the right to have Colorado School of Mines- Athletic Training use only confidential means of communicating with you about medical information. This means you may have information delivered to you at a certain time or place, or in a manner that keeps your information confidential.

Access. You have the right to see and receive a copy of information about you kept by Colorado School of Mines- Athletic Training under most circumstances.

Amendment. You have the right to have Colorado School of Mines- Athletic Training amend its records of information about you. Colorado School of Mines- Athletic Training may refuse to amend information that is accurate, that was created by someone else, or is not disclosable to you.

Accounting. You have the right to see a list of certain disclosures of medical information about you by Colorado School of Mines- Athletic Training, which includes the purposes and recipients of the information.

Copy. You have the right to receive a paper copy of this notice.

Privacy Notice. Colorado School of Mines- Athletic Training is required by law to keep medical information about you private and to give you this notice. Colorado School of Mines- Athletic Training must abide by this notice; however, we reserve the right to amend this notice and make such change applicable to all medical information maintained in our facility. We will provide a revised notice to patients by posting the new notice in the waiting room of the student health center.

Complaints. You may complain to Colorado School of Mines- Athletic Training if you believe your privacy rights have been violated by giving a written complaint to the Privacy Officer at Colorado School of Mines- Athletic Training 1500 Illinois St. Golden, CO 80401. You may also complain to the Secretary of the U.S. Department of Health and Human Services. Colorado School of Mines- Athletic Training will not retaliate against you for making a complaint.

Effective Date. This notice is effective from April 14, 2004 until revised by Colorado School of Mines- Athletic Training.

CONCUSSIONA fAct sheet for student-Athletes

What is a concussion? A concussion is a brain injury that:

• Is caused by a blow to the head or body.– From contact with another player, hitting a hard surface such

as the ground, ice or floor, or being hit by a piece of equipmentsuch as a bat, lacrosse stick or field hockey ball.

• Can change the way your brain normally works.• Can range from mild to severe.• Presents itself differently for each athlete.• Can occur during practice or competition in ANY sport.• Can happen even if you do not lose consciousness.

hoW can i prevent a concussion?Basic steps you can take to protect yourself from concussion:

• Do not initiate contact with your head or helmet. You can still geta concussion if you are wearing a helmet.

• Avoid striking an opponent in the head. Undercutting, flyingelbows, stepping on a head, checking an unprotected opponent,and sticks to the head all cause concussions.

• Follow your athletics department’s rules for safety and the rules ofthe sport.

• Practice good sportsmanship at all times.• Practice and perfect the skills of the sport.

it’s better to miss one game than the Whole season. When in doubt, get checked out.For more information and resources, visit www.NCAA.org/health-safety and www.CDC.gov/Concussion.

What are the symptoms of a concussion?You can’t see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. Concussion symptoms include:

• Amnesia.• Confusion.• Headache.• Loss of consciousness.• Balance problems or dizziness.• Double or fuzzy vision.• Sensitivity to light or noise.• Nausea (feeling that you might vomit).• Feeling sluggish, foggy or groggy.• Feeling unusually irritable.• Concentration or memory problems (forgetting game plays, facts,

meeting times).• Slowed reaction time.

Exercise or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games may cause concussion symptoms (such as headache or tiredness) to reappear or get worse.

What should i do if i think i have a concussion? Don’t hide it. Tell your athletic trainer and coach. Never ignore a blow to the head. Also, tell your athletic trainer and coach if one of your teammates might have a concussion. Sports have injury timeouts and player substitutions so that you can get checked out.

Report it. Do not return to participation in a game, practice or other activity with symptoms. The sooner you get checked out, the sooner you may be able to return to play.

Get checked out. Your team physician, athletic trainer, or health care professional can tell you if you have had a concussion and when you are cleared to return to play. A concussion can affect your ability to perform everyday activities, your reaction time, balance, sleep and classroom performance.

Take time to recover. If you have had a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have a repeat concussion. In rare cases, repeat concussions can cause permanent brain damage, and even death. Severe brain injury can change your whole life.

Reference to any commercial entity or product or service on this page should not be construed as an endorsement by the Government of the company or its products or services.

What is sickle cell trait?

Know your sickle cell trait status.

Engage in a slow and gradual preseason conditioning regimen.

Build up your intensity slowly while training.

Set your own pace. Use adequate rest and recovery between repetitions, especially during “gassers” and intense station or “mat” drills.

Avoid pushing with all-out exertion longer than two to three minutes without a rest interval or a breather.

If you experience symptoms such as muscle pain, abnormal weakness, undue fatigue or breathlessness, stop the activity immediately and notify your athletic trainer and/or coach.

Stay well hydrated at all times, especially in hot and humid conditions.

Avoid using high-caffeine energy drinks or supplements, or other stimulants, as they may contribute to dehydration.

Maintain proper asthma management.

Refrain from extreme exercise during acute illness, if feeling ill, or while experiencing a fever.

Beware when adjusting to a change in altitude, e.g., a rise in altitude of as little as 2,000 feet. Modify your training and request that supplemental oxygen be available to you.

Seek prompt medical care when experiencing unusual physical distress.

People at high riskfor having sickle cell trait are those whose ancestors come from Africa, South or Central America, India, Saudi Arabia and Caribbean and Mediterranean countries.

sickle cell trait is not adisease. Sickle cell trait is the inheritance of one gene for sickle hemoglobin and one for normal hemoglobin. Sickle cell trait will not turn into the disease. Sickle cell trait is a life-long condition that will not change over time.

A FAct Sheet For Student-AthleteS

Do you knoW if you have sickle cell trait?

hoW can i Prevent a collaPse?

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SICKLE CELL TRAITDuring intense exercise, red blood cells containing the sickle hemoglobin can change shape from round to quarter-moon, or “sickle.”

Sickled red cells may accumulate in the bloodstream during intense exercise, blocking normal blood flow to the tissues and muscles.

During intense exercise, athletes with sickle cell trait have experienced significant physical distress, collapsed and even died.

Heat, dehydration, altitude and asthma can increase the risk for and worsen complications associated with sickle cell trait, even when exercise is not intense.

Athletes with sickle cell trait should not be excluded from participation as precautions can be put into place.

Sickle cell trait occurs in about 8 percent of the U.S. African-American population, and between one in 2,000 to one in 10,000 in the Caucasian population.

Most U.S. states test at birth, but most athletes with sickle cell trait don’t know they have it.

The NCAA recommends that athletics departments confirm the sickle cell trait status in all student-athletes.

Knowledge of sickle cell trait status can be a gateway to education and simple precautions that may prevent collapse among athletes with sickle cell trait, allowing you to thrive in your sport.

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For more information and resources, visit www.NCAA.org/health-safety

Colorado School of Mines Athletics Medical History Questionnaire

This is a confidential record of your medical history. Information contained herein will not be released to anyone except CSM Team Physicians and CSM Athletic Trainers until you have authorized us to do so. You understand that this information may be used and disclosed by CSM Team Physicians and CSM Athletic Trainers to provide emergency medical care to you without your express authorization. I give permission for the CSM Team Physicians and CSM Athletic Trainers to perform evaluations and treatment for injuries incurred in my sport. I understand the medical expenses incurred for medical care are my responsibility and are not the responsibility of CSM Athletic Trainers, CSM Athletic Department or treating physicians. I understand that the results of this questionnaire may result in further evaluation by CSM Team Physicians before I am cleared to participate. I will be financially responsible for any additional evaluations or tests as needed.

Today’s Date: CSM E-Mail: CSM CWID:

Last Name: First Name: Middle Initial:

DOB (mm/dd/yyyy): Age: Marital Status:

Sport: Eligibility Year:

ALLERGIES – Are you allergic to any of the following:

Yes No Medicines

please list:

Yes No Stinging Insects

Yes No Food

please list:

Yes No Latex

Yes No Adhesive Tape

Yes No Pollens, Dust, Grass, Natural Allergens

Yes No Detergents

Yes No Other:

MEDICATIONS AND SUPPLEMENTS – List any medications or supplements you are currently taking:

MEDICATION / SUPPLEMENT NAME REASON TAKING DATE BEGAN TAKING

FAMILY HISTORY – Has any family member or blood relative:

Yes No Died of heart problems or had an unexpected or unexplained sudden death before age 50 (including drowning,

unexplained car accident or sudden infant death syndrome)?

Yes No Have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT

syndrome, short QT syndrome, Brugada syndrome or catecholaminergic polymorphic ventricular tachycardia?

Yes No Have a heart problem, pacemaker or implanted defibrillator?

Yes No Had unexplained fainting, unexplained seizures or near drowning?

rev. May 2013 1 of 4

STUDENT-ATHLETE HISTORY

INJURIES – Have any of the following happened to you:

Provide specific information/details with any “Yes” answers. Attach additional documentation or medical records where necessary.

List all ligament sprains, muscle strains, joint dislocations, stress fractures and bone fractures you’ve had in the last 4 years:

Injury: Body Part: Side: Date (mm/yyyy):

Injury: Body Part: Side: Date (mm/yyyy):

Injury: Body Part: Side: Date (mm/yyyy):

Injury: Body Part: Side: Date (mm/yyyy):

List all surgeries/operations you’ve had in the past 4 years including date of surgery:

Yes No Have you ever been advised to have surgery which has not been done?

If “Yes” please explain:

Yes No Have you ever been advised by a physician not to participate in sports?

If “Yes” please explain:

Yes No Have you ever been hospitalized?

If “Yes” please explain:

Yes No Have you ever had an injury that required x-ray, MRI, CT, injection, therapy, brace, cast or crutches?

Yes No Have you ever had numbness, tingling or weakness in your arms or legs after being hit or falling?

Yes No Have you ever been unable to move your arms or legs after being hit or falling?

Yes No Concussion, head injury or blow to the head that caused confusion, headache or memory problem?

How many from athletics? How many from other causes?

Most recent date (mm/yyyy)

Second date (mm/yyyy)

Third date (mm/yyyy)

Yes No Back pain, If “Yes” where?

Yes No Neck pain?

Yes No Have you ever been told you have had to have an x-ray for neck instability or atlantoaxial instability?

Yes No Stinger or burner, If “Yes” which side?

MEDICAL QUESTIONS

Yes No Have you ever been tested for Sickle Cell Trait?

Was the test positive? Yes No

Yes No Were you born without or are you missing a kidney, eye, testicle, spleen or any other organ?

Yes No Do you have a groin pain or a painful bulge or hernia in the groin area?

Yes No Have you had infectious mononucleosis (mono) within the last month?

Yes No Do you have any rashes, pressure sores, or other skin problems?

Yes No Have you had a herpes or MRSA skin infection?

Yes No Do you have any ongoing medical conditions? Anemia Diabetes Infections

Yes No Have you ever been diagnosed with ADD or ADHD?

Yes No Have you ever had chicken pox or shingles?

WOMEN ONLY

Date of last period (mm/dd/yyyy): Regular? Yes No

rev. May 2013 2 of 4

STUDENT-ATHLETE HISTORY (Continued)

GENERAL MEDICAL QUESTIONS – Do you have now or have you had any of the following:

HEAD Yes No Frequent / severe headache Yes No Headache during or after exercise

Yes No Difficulty Concentrating

Yes No Migraines

VISION

Yes No Vision Problems (double, spots, tunnel)

Yes No Any eye injuries or infection

Yes No Do you wear glasses

Yes No Do you wear contacts

Yes No Wear contacts during competition

HEARING

Yes No Hearing problems

NOSE

Yes No Recurrent nosebleeds

Yes No Sinus trouble or infection

ORAL

Yes No Difficulty swallowing

Yes No Soreness or bleeding of gums

Yes No Coughed up blood

RESPIRATORY

Yes No Cough or wheeze during / after exercise

Yes No Difficulty breathing during / after exercise

Yes No Asthma or exercise induced asthma

Yes No Use an inhaler or take asthma medicine

Yes No Use an inhaler during exercise

ORTHOPEDIC Yes No Wear orthotics or brace

Yes No Recurrent neck pain

Yes No Swollen, painful, warm or red joints

Yes No Frequent muscle spasms or cramps

Yes No Juvenile arthritis

ENVIRONMENTAL

Yes No Inability to tolerate heat

Yes No Inability to tolerate cold

Yes No Heat exhaustion

Yes No Heat stroke

Yes No Become ill while exercising in heat

NERVOUS

Yes No Pain in arms with or w/o being hit

Yes No Tingling or weakness in hands or feet

Yes No Dizziness with activity

GASTROINTESTINAL / URINARY

Yes No Recurrent stomach pain/heartburn

Yes No Nausea or vomiting

Yes No Abdominal cramps

Yes No Pain with urinating

Yes No Blood or dark colored urine

WEIGHT

Yes No Do you worry about your weight

Yes No Are you trying to gain or lose weight

Yes No Ever had an eating disorder

Yes No On a special diet or avoid certain food

HEART HEALTH QUESTIONS Yes No Have you ever passed out or nearly passed out during or after exercise?

Yes No Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?

Yes No Does your heart ever race or skip beats (irregular beats) during exercise?

Yes No Has a doctor ever ordered a test for your heart (ECG/EKG, echocardiogram)?

Yes No Do you ever get lightheaded or feel more short of breath than expected during exercise?

Yes No Have you ever had an unexplained seizure?

Yes No Do you get more tired or short of breath more quickly than your friends during exercise?

Yes No Has a doctor ever told you that you have any heart problems? If yes check all that apply:

High blood pressure Heart murmur High cholesterol

Heart infection Kawasaki disease Other

rev. May 2013 3 of 4

Please include copies of all physicians’ reports regarding any surgery or hospitalization you have had in the past year.

I certify that all answers to the above statements are correct and true to the best of my knowledge.

I understand that Colorado School of Mines is not responsible for any previous medical conditions.

Signed: ___________________________________________________________ Date: _____________________________ Parent / Guardian (Only if student is under 18)

Signed: ___________________________________________________________ Date: _____________________________ Student-Athlete

Signed: ___________________________________________________________ Date: _____________________________ CSM Athletic Trainer

rev. May 2013 4 of 4

Colorado School of Mines Athletics Acknowledgement of Risk

Last Name: First Name: Middle Initial: CWID:

This is a warning to you, as a student-athlete, of the risk you take by participating in varsity athletics at Colorado School of Mines (CSM). By participating in any varsity athletics at CSM, you may sustain any one of the following injuries. This list is not conclusive, as there are other injuries that can occur to you while participating in varsity athletics at CSM. This acknowledgement, and list of injuries, is given to you to make you aware of the inherent dangers and risks involved while participating in varsity athletics at CSM.

1. Head Injuries – Can result in permanent brain damage, coma and/or death.2. Neck or Back Injuries – Can result in quadriplegia, paraplegia and/or death.3. Strains – Completely torn, partially torn and/or stretched muscles, tendons or musculotendinous units.4. Sprains – Completely torn, partially torn and/or stretched ligaments.5. Contusions – Impact injuries.6. Lacerations, Abrasions and Other Skin Injuries – Can result in infection.7. Internal Organ Injuries – Can result in internal bleeding (i.e. ruptured spleen, kidney, liver, etc.).8. Loss of Limb or Vital Organ9. Cartilage – Damaged meniscus or cartilage in the joints of the body.

There are other injuries / illnesses that are not included in this list. This acknowledgement is to make you aware of the seriousness and extent of various types of possible injuries that can occur to YOU while participating in varsity athletics at CSM.

I have read the above and understand what it states. In consideration of Colorado School of Mines allowing me to participate in varsity athletics, the undersigned Participant and Parent or Guardian, if appropriate, agree to hold harmless, release, indemnify and forever discharge Colorado School of Mines, and its Board of Trustees, officers, directors, employees, agents, and any persons acting on their behalf, as well as their heirs, executors and assigns from and against any and all liability, claims, demands, costs and expenses (including attorneys’ fees) arising out of or in any way connected with any bodily injury or property damage in any way relating to or arising out of my participation in varsity athletics, even if the liability, claims, demands, costs and expenses may arise, in whole or in part, out of the negligence or carelessness of the persons or entities mentioned above.

Signed: ________________________________________________ Date: _____________________________ Parent / Guardian (ONLY if student is under 18)

Signed: _________________________________________________ Date: _____________________________ Student-Athlete

rev. May 2013

Colorado School of Mines Athletics Injury & Illness Reporting Policy

Last Name: First Name: Middle Initial: CWID:

I acknowledge that I have to be an active participant in my own healthcare. As such, I have the direct responsibility for reporting all of my injuries and illnesses to the sports medicine staff of Colorado School of Mines (e.g., team physician, athletic training staff). I recognize that my true physical condition is dependent upon as accurate medical history and a full disclosure of any symptoms, complaints, prior injuries and/or disabilities experienced. I hereby affirm that I have fully disclosed in writing any prior medical conditions and will also disclose any future conditions to the sports medicine staff at Colorado School of Mines.

In the event of an injury during practice or competition, no matter how slight, I understand and agree that I must report immediately to the Athletic Trainer of that sport. The Athletic Trainer will initiate the appropriate care.

Referral to Outside Health Care Providers: Referral to physicians, including specialists, nurse practitioners, chiropractors, physical therapists and other health care providers will be made only by a Colorado School of Mines Athletic Trainer. If you choose not to consult your assigned Athletic Trainer to obtain referral for outside services or surgeries on an athletic related injury, the rehabilitation of that injury will not be the responsibility of the athletic training staff.

Post-Injury/Illness Medical Clearance: Any athlete who sustains an injury or illness that requires outside medical attention (Emergency Department, off-campus physician, etc.) needs a written letter of medical clearance from the treating Physician. The athlete will not be medically eligible to participate until the Physician signed document is presented to the athlete’s Athletic Trainer.

Concussion Reporting and Education: I further understand that there is a possibility that participation in my sport may result in a head injury and/or concussion. I have been provided with education on head injuries and understand the importance of immediately reporting symptoms of a head injury/concussion to a member of the sports medicine staff.

By signing below, I acknowledge that my institution has provided me with specific educational materials on what a concussion is and given me an opportunity to ask questions about areas and issues that are not clear to me on this issue.

I have read the above and agree that the statements are accurate.

Signed: ________________________________________________ Date: ____________________ Parent / Guardian (ONLY if student is under 18)

Signed: ________________________________________________ Date: ____________________Student-Athlete

rev. May 2013

Colorado School of Mines Athletics Acknowledgement of Insurance Requirements

Last Name: First Name: Middle Initial: CWID:

Sport: DOB (mm/dd/yyyy): Eligibility Year:

This form must be SIGNED by the student-athlete prior to participating in Colorado School of Mines Athletics practice and/or competition. The CSM Athletic Training Staff must have scanned the student-athlete's current health insurance card PRIOR to the student-athlete participating in

Colorado School of Mines Athletics practice and/or competition.

POLICY HOLDER INFORMATION

Policy Holder Last Name: First Name: Middle Initial:

Relationship to Student-Athlete:

INSURANCE INFORMATION

Name:

Type of Policy: Member ID#

Policy Limit (MUST be at least $90,000):

Does this policy cover injuries incurred during intercollegiate athletics participation? Yes No

I, (student-athlete name) attest that I have insurance coverage under a current, in force insurancepolicy for injuries that occur while I am participating in intercollegiate athletics. This coverage has limits of at least $90,000.

If there is a material change in coverage or expiration of coverage, I agree to notify the Colorado School of Mines of this development and update the insurance information I have on file with the Colorado School of Mines.

I understand and agree that the Colorado School of Mines will assume no responsibility whatsoever for the payment of, or authorization to pay, medical expenses resulting in injuries that occur while participating in intercollegiate athletics at the Colorado School of Mines.

I have read and agree to comply with the provisions of the Acknowledgement of Insurance Requirements.

Signed: Parent / Guardian (Only if student is under 18)

Signed: Student-Athlete

Date:

Date:

Colorado School of Mines Athletics Sickle Cell Trait Testing & Waiver

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 is a common condition (> three million Americans) 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. An undiagnosed trait can be dangerous, even fatal. During intense, sustained exercise, hypoxia (lack of oxygen) in the muscles may cause sickling of 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 block blood vessels, leading to collapse from the rapid breakdown of muscles starved of blood and possible death. More information on sickle cell trait may be found at the following NCAA website: www.NCAA.org/health-safety

Sickle Cell Trait Testing

The NCAA mandates that all Division II student-athletes have knowledge of their sickle cell trait status before participating in athletic-related activities including intercollegiate athletics events, strength and conditioning sessions, practices, competitions, etc.

INSERT YOUR NAME AND SELECT ONE OF THE THREE OPTIONS BELOW:

NAME: CSM CWID: SPORT:

1. A copy of my sickle cell trait test from a physician or other authorized medical care provider is attached.

2. I would like to be tested as part of my pre-participation physical examination. I understand that there may be a delay in mymedical clearance and that the results will be shared with the team physician.

3. I voluntarily decline to be tested and understand that an undiagnosed trait can be dangerous, even fatal, and agree to sign thewaiver below. IF YOU CHOOSE THIS OPTION YOU MUST SIGN THE WAIVER BELOW.

SICKLE CELL TRAIT TESTING WAIVER AND RELEASE OF CLAIMS (ONLY COMPLETE IF OPTION 3 IS SELECTED ABOVE)

I, (student-athlete name), understand and acknowledge that the NCAA and Colorado School of Mines mandates all NCAA Division II student-athletes be tested for sickle cell trait, show proof of a prior test, or sign a waiver releasing the school from liability if they decline to be tested before participating in athletic-related activities. 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 other disabilities experienced. I hereby affirm that I have fully disclosed in writing any knowledge of sickle cell trait status to the Colorado School of Mines Athletic Training staff.

I do not wish to undergo sickle cell testing as part of my pre-participation physical exam and I voluntarily agree to release, discharge, indemnify and hold harmless Colorado School of Mines, their respective officers, coaches, associated medical staff, instructors, agents or employees 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 voluntary decision not to be tested.

I, the undersigned, have read this release and understand its terms. I execute it voluntarily and with full knowledge of its significance.

Signed: ___________________________________________________________ Date: _____________________________ Parent / Guardian (Only if student is under 18)

Signed: ___________________________________________________________ Date: _____________________________ Student-Athlete

May 2013