Athletic Participation Form
The KWC Athletic Training Department provided by One Health/Owensboro Health Regional Hospital (OHRH) must have these forms completed in their entirety before you will be allowed to participate in any team related activities including weight lifting, individuals, practice or competitions. If you have any questions, please contact Marty Daniel at 765-499-0068 or Alex Vogel at 567-230-2664.
Kentucky Wesleyan College Athletic TrainingAssumption of Risk 2019-2020
The undersigned herewith formally acknowledges and declare the following:I, , understand that participation in sport requires a personal acceptance of risk of injury. Athletes generally expect that those who are responsible for the conduct of sport take reasonable precautions to minimize such risk and that their peers participating in the sport will not intentionally inflict wrongful injury upon them.I understand that participation in Intercollegiate Athletics at Kentucky Wesleyan College may result in injury/illness, permanent physical or mental impairment or even death. These injuries may include,but are not limited to; head injuries, neck or back injuries, strains, sprains, contusions, lacerations, internal organ injuries, loss of limb or vital organ, or cartilage injury; may be minor or may be career ending or life threatening. I understand that Kentucky Wesleyan College cannot be held responsible for any injuries or conditions that may be caused by the actions of other athletes or teams. I also understand that injuries may be caused by my own failure to follow safety procedures or techniques which are made known to me by my coaching staff, athletic training staff, or by the strength and condition personnel or are otherwise known to me from another source including but not limited to medical personnel of the college.
I have read the above shared responsibility statement. I understand that there are certain inherent risks involved in participating in intercollegiate athletics. I acknowledge the fact that these risks exist and I am willing to assume responsibility for any and all such risks while participating in Intercollegiate Athletics at Kentucky Wesleyan College. I also agree to the following: All injuries and illnesses must be reported to the athletic trainer immediately. The coaches at Kentucky Wesleyan College are NOT athletic trainers. The athletic trainers are NOT liable for injuries sustained during practices and/or games. The athletic trainer will make any necessary referrals to our team physician. Parents and athletes SHOULD NOT set up appointments without approval from their Head Athletic Trainer. If an appointment is set by someone other than the Kentucky Wesleyan Athletic Training staff, all bills will become the responsibility of the athlete and/or their parents. I voluntarily assume all risks associated with my participation in Intercollegiate Athletics. I voluntarily assume all costs, including deductibles, co-pays, medical bills etc. incurred as a result of injuries or illness associated with my participation in Intercollegiate Athletics. I accept and agree that Kentucky Wesleyan College and its personnel are not to be held responsible for any pre-existing medical condition(s) that I may have. I understand that I must refrain from practice while injured or ill, whether or not receiving medical care. When under medical care I may not return to participation until I have been given permission, based on independent exercise of professional judgment, by the Head Athletic Trainer, or the Team Physician after review of my condition and fitness for the rigors of my sport. This may occur during or at the conclusion of medical treatment(s). I understand that having passed the physical examination does not necessarily mean that I am physically qualified to participate in Intercollegiate Athletics at Kentucky Wesleyan College, but only that the doctor did not find a medical reason to disqualify me at the time of the physical examination. I understand that if I experience an injury/illness or change in my health status, including signs and symptoms of concussion according to the educational material provided to me, it is my responsibility to immediately inform the Head Athletic Trainer and to adhere to the established injury management guidelines which includes rehabilitation, reassessments and clearance before I am released to return to full participation. I understand that I must wear the proper equipment as dictated by the rules of the sport. I may also have to wear padding or braces as indicated by the Head Athletic Trainer or Team Physician. Failure to do so may put me at risk for further injury. By my signature on this document, I hereby release and hold harmless the Board of Trustees of Kentucky Wesleyan College, by and through Kentucky Wesleyan College, its officers, faculty, and employees from any and all liability that may arise from my participation in intercollegiate athletics. I further agree to not sue, or otherwise assert claims against Kentucky Wesleyan College regarding my participation in intercollegiate athletics.
Kentucky Wesleyan College Sports MedicineStudent-Athlete Concussion Statement and Injury Awareness FormImPACT Concussion Baseline Testing 2019-2020
I understand that it is my responsibility to report all injuries and illnesses to my athletic trainer and/or team physician.
I have read and understand the NCAA Concussion Fact Sheet on www.ncaa.org/health-safety
After reading the NCAA Concussion Fact Sheet, I am aware of the following information:
A concussion is a brain injury, which I am responsible for reporting to my team physician or athletic trainer. A concussion can affect my ability to perform everyday activities and affect reaction time, balance, sleep and classroom performance. You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. If I suspect a teammate has a concussion, I am responsible for reporting the injury to my team physician or athletic trainer. I will not return to play in a game or practice if I have received a blow to the head or body that results in concussion-related symptoms until I have been cleared by my team physician or athletic trainer. Should I sustain a concussion, I will not take ANY medication unless told to do so by my team physician or athletic trainer. This includes but not limited to Tylenol, Advil or Aleve. Following a concussion, the brain needs time to heal. You are more likely to have a repeat concussion if you return to play before your symptoms resolve. In rare cases, repeat concussions can cause permanent brain damage and even death.
Upon arrival to Kentucky Wesleyan College, the Owensboro Health Athletic Training staff will conduct concussion baseline testing during the On Campus Pre-participation Physical Examination. Should I receive a concussion, the results of test will be used as a supplemental assessment tool evaluate their progress in healing and return to play status with the team physician making the final decision. Please see the KWC Athletic Training Staff with any questions.
Kentucky Wesleyan College Athletic Training Consent to Treat Form 2019-2020
I understand that my injury/illness information is protected by federal regulation under with the Health Information Portability and Accountability Act (HIPAA) of Family Education Rights and Privacy Act of 1974 (the Buckley Amendment) and may not be disclosed without either my authorization under HIPAA or my consent under the Buckley Amendment.
I, the above named student-athlete, give authorization to One Health/Owensboro Health Regional Hospital Athletic Training Staff and Team Physicians to evaluate and treat any injuries, illnesses or medical conditions that occur during my athletic participation at Kentucky Wesleyan College. (This includes immediate first aid, medication and treatment, x-ray, physical exam, follow-up care and rehabilitation.) I understand the team physician has the authority to eliminate me from further participation due to an injury, illness or other medical condition and/or the undue liability risk of Kentucky Wesleyan College.
I further hereby authorize the KWC Athletic Training Staff and Team Physicians to evaluate and treat any injuries that occur during my athletic participation at Kentucky Wesleyan College. I acknowledge and agree that all future injuries, medical/dental/mental problems, ailments, complaints, re-injuries, and aggravations of old injuries must be immediately reported to the team Athletic Training certified staff member, Team Physician or the campus health/mental health staff no matter how minor or insignificant I may deem them to be. I understand that it is my responsibility to report ALL injuries and illnesses to the Kentucky Wesleyan College Athletic Training Staff including, but not limited to, signs and symptoms of concussion. I understand that it is my responsibility to report any outside visits to physical therapists, doctors, or other related medical staff to the Kentucky Wesleyan College Athletic Training Staff.
I understand that the Team Physician or his designee has the authority to withhold me from further participation because of injury and/or because of an undue liability/risk to Kentucky Wesleyan College.
I understand that within one month of completion of my final year of eligibility, or exit from team roster, I am responsible for completing an exit physical. Failure to complete the exit physical may release Kentucky Wesleyan College from any medical liability and/or financial responsibility for any and all athletic related injuries.
Kentucky Wesleyan College Athletic Training Insurance requirements 2019 - 2020
Please read all information carefully. It is imperative that you understand and provide accurate and complete information regarding your son/daughters medical insurance coverage.
Medical Insurance Requirements: Parents, please keep for your information
All student athletes must provide proof of primary insurance that provides coverage for and is payable in the State of Kentucky. Please check with your insurance company and be familiar with your companies’ out-of-state and traveling policies. Kentucky Wesleyan College does NOT offer school insurance for student/athletes to purchase. Therefore, each athlete must have personal insurance. Should your son/daughter age out or there is a lapse in your primary insurance, you will need to provide proof of another valid insurance. The Athletic Training Department must have proof of insurance before the student-athlete will be allowed to participate in any conditioning, team related conditioning, practice, competition or any team associated activities. Proof of insurance can be supplied by providing one copy, front and back, of the primary insurance card. Please complete the following Student Athlete Insurance Information Form to follow. Athletes will be held out of all practices and games until the Athletic Training Department has proof of valid Medical Insurance.
Kentucky Wesleyan College has a “secondary” or “excess” insurance plan i.e., KWC Comprehensive Athletic Insurance Plan. This will go into effect AFTER your primary insurance has paid their benefits up to $1500.00. First, your primary insurance will be billed. Secondly, after payment of $1500.00 has been met by your insurance, the Kentucky Wesleyan College (deductible $1500.00) will then collect the remaining balances. Remaining balances are provided by the student-athlete bringing in the “explanation of benefits” (EOB) and bills sent from your primary insurance company to the KWC Insurance Coordinator, Bill Hume. Copays from your primary insurance will be paid by providing dated, itemized receipts to the KWC Insurance Coordinator for reimbursement. This form must be completed. You will not be allowed to participate until the Athletic Training Staff has received this information. **If you are an International Student-Athlete please be sure that you have travel insurance that is valid in the USA.**
Kentucky Wesleyan College Athletic TrainingInsurance Policy Checklist 2019-2020
I verify that the image below is a copy of my primary insurance card
I understand that I am required to have primary insurance as a student-athlete and that I am required to have an updated insurance card on file with the KWC Athletic Training Staff. Should I age out or my insurance changes, it is my responsibility to notify KWC Athletic Training of the new policy information.
I understand that my insurance policy must cover athletic injuries that occur in the State of Kentucky.
I understand that Kentucky Wesleyan College carries a secondary insurance policy. This policy requires the athlete’s primary insurance policy to pay to the limits of its ability. Any unpaid or excess is then paid by KWC Comprehensive Secondary Athletic Insurance Plan after $1500.00(deductible) has been met by primary insurance.
I understand that it is my sole responsibility to update the KWC Athletic Training Staff of any changes that occur to my insurance coverage.
I understand that in the event that I do not have insurance at the time of athletic injury (aging out or lapse in insurance coverage) and I fail to notify the KWC Athletic Training Staff of such, I will be held responsible for all bills and costs incurred.
I understand that under no circumstances is the KWC Department of Athletics responsible for medical bills, injuries or illnesses NOT incurred during intercollegiate athletic practices or games. The secondary (excess) insurance coverage provided by Kentucky Wesleyan College is for ATHLETIC- RELATED INJURIES ONLY. Therefore, only those injuries sustained while participating in a supervised practice or event will be covered. This does include off-season conditioning programs, but NOT include events such as summer leagues, intramurals, pick-up games, recreational activities, etc.
I understand that if I use an outside physician, physical therapist, or any other healthcare provider without PRIOR notification and written approval through the KWC Athletic Training Staff; the Department of Athletics and the Athletic Training Staff is NOT responsible for any incurred bills. This includes Second Opinions.
I understand that if I do NOT wear required equipment (mouthpiece, head gear, helmet, ETC) and I suffer an injury, the Department of Athletics and Athletic Training Staff will NOT be responsible for medical expenses related to the injury.
I understand that I have ONE year from the date of initial injury, to complete all medical treatment for that injury. KWC will not be responsible for any medical costs after the first year.
I understand that if I have a concern regarding medical care or insurance coverage, I should communicate with the Head Athletic Trainer or Insurance Coordinator about concerns.
I understand that I must report all injuries to the Athletic Training Staff immediately. If injured at an away competition with no traveling ATC present; I must report the injury to the coach. They will then seek medical assistance from the host ATC. It is the student-athletes responsibility to see the Athletic Training Staff immediately upon arrival from the competition.
I fully understand and agree to abide by the Kentucky Wesleyan College Athletics Insurance Policy and other policies as listed above.
I understand that I must bring in any bills, should any injury occur, that are not paid by my insurance company to the Insurance Coordinator, for payment.
Kentucky Wesleyan College Athletic Training Student Athlete Insurance Information 2019-2020
Athletes Full Name: Sport:
Athlete's SSN: Date of Birth: Gender:
Parent/Guardian Name: Home Address:
Phone Number: Email:
Policy #: Group#: Certificate/ID#:
Please review the list below, if your insurance is listed, please contact your insurance provider to get pre-approval to be seen by the providers at Owensboro Health Medical Group Orthopedics. When using TriCare, it is important to update your primary care physician to our team physician so any medical care provided is easily covered.Contact Alex Vogel at email@example.com for information on this process.
HIP MHS HIP MDWise Hoosier Healthwise MHS Hoosier Healthwise MDWise Hoosier Care Connect MHS Hoosier Care Connect MDWise Anthem Medicaid Patoka Valley AARP Medicare Complete HMO Indiana Anthem HIP - CareSource Indiana MDWise TriCare West TriCare Prime
Preauthorization Required: Copay Amount: Insurance Type:
I have reviewed all the insurance policy information on this page. I agree that all the information is correct. If any of the information is incorrect, I will contact the KWC Athletic Training Staff and supply the correct information.
I hereby authorize a claim to be filed on my behalf under the medical insurance policy in the event an athletic injury is sustained by my son or daughter named above.
I hereby authorize our institution to inspect or secure copies of case histories, lab reports, diagnosis, x-rays, MRIs and other data on this and/or previous confinements and/or disabilities. A photo copy of this form shall be deemed as valid as the original.
Kentucky Wesleyan College Athletic TrainingMedical History Form 2019-2020
Previous Injury or Illness:
I have answered each question on the Medical History Form honestly and accurately. I understand that during my Pre-Participation Physical, it is my responsibility to fully disclose all pre-existing injuries and/or medical conditions. Failure to report these injuries or illnesses during the Pre-Participation Physical will relieve Kentucky Wesleyan College of any and all liability in the event that I, the student-athlete, receive an injury to the same or related areas, provided the original injury was a contributing factor. Any diagnostics required by the team physician to clear me, the student-athlete, for athletic participation will be my responsibility and is not the responsibility of the KWC Athletic Training Room or KWC Athletic Department. The Athletic Training staff will review all injuries and illnesses on the Medical History Form. I understand that if any medical condition or illness is discovered during the PPE, I will NOT be allowed to practice or compete until cleared by our team physician. The team physician will have the final say when determining an athletes’ status for participation in athletics and returning to sport. I understand the KWC Athletic Training Room and Athletic Department will NOT pay the cost to repair any previous injury incurred prior to reporting for any athletic program or preseason camps.
Injury/Illness Policy I understand that all injuries and illnesses are to be reported to the Athletic Training Staff for treatment or referral on the day of occurrence, or within 24 hours of injury if traveling. It is my responsibility to report all injuries to the athletic trainer not the coach. The KWC Athletic Training Staff is a part of the hospital; all referrals to the team physician are arranged through the Athletic Training Staff ONLY. Emergency medical treatment is the only exception.
I understand that any Student-athlete obtaining medical services outside of Kentucky Wesleyan College’s team physician must obtain permission from their Athletic Trainer responsible for their sport prior to the date of service. Failure to obtain permission releases Kentucky Wesleyan College from any and all financial liability for services which then becomes the student-athletes responsibility.
Kentucky Wesleyan College Athletic TrainingPre-Participation Physical Examination Medical History Form 2019-2020
This is a confidential record of your medical history. Information contained herein will not be released to anyone except authorized campus health/mental health staff without written notification authorizing the KWC Athletic Training Staff and Team Physicians to do so. Exceptions will be for emergency medical care should the need arise.
Please note that every athlete must undergo a Pre-Participation Physical. The cost of the physical is $10.00 and payment will be taken on team move-in day in August. Payments accepted are cash or check.
Student-Athlete Name: Student SSN: Date of Birth:
Biological Father: Age: Health: Deceased: Age at death(If still living, leave blank): Cause (If still living, leave blank):
Biological Mother: Age: Health: Deceased: Age at death (If still living, leave blank): Cause (If still living, leave blank):
Have any of your parents/siblings ever been diagnosed with or treated for
STUDENT ATHLETE HISTORY Injuries- If you have had no injuries in the within the last four years, this section will be blank.
Injury: Body Part: Body Side: Injury Date:
Injury: Body Part: Body Side: Injury Date:
Injury: Body Part: Body Side: Injury Date:
Surgeries- If you have had no surgeries in the last four years, this section will be blank.
Surgery: Surgery Date:
Surgery: Surgery Date:
Surgery: Surgery Date:
Have you ever been advised to have surgery which has not been completed? .
Have you ever been advised by a physician not to participate in sports? .
Have you ever been hospitalized other than for surgeries listed above? .
Involved in a motor vehicle accident? .
Concussion or head injury?
If you have had no concussions, this section will be blank.
How many from athletics? How many from other causes? Most recent concussion date: Second most recent concussion date:
Do you currently have or have ever had a
Do you have now or have you had any of the following in the past year?
Have you had or been diagnosed with any of the following:
I understand that if I have Asthma, I will give an extra inhaler to the athletic trainer to keep in their kit for use at practices and competitions.
Do you have any allergies that could require emergency treatment?
These allergies are (if there are no allergies that could require emergency treatment, this list will be blank):
MEDICATIONS AND SUPPLEMENTS:
WOMEN ONLY: If you are a male, this section will be blank.
Is your menstrual cycle regular: Are you on birth control?
I certify that all answers to the above statements are correct and true to the best of my knowledge. I understand that Kentucky Wesleyan College is not responsible for any previous medical conditions.
Kentucky Wesleyan College Athletic TrainingRelease of Medical Information-HIPPA Form 2019-2020
This authorizes the Athletic Training Staff, Team Physicians representing Kentucky Wesleyan College to release information concerning my medical status, medical condition, injuries, prognosis, diagnosis, and related personally identifiable health information to all of the following relevant to past, present or future participation in athletics at Kentucky Wesleyan College.
Please initial appropriate parties that you are willing to release medical information to:
KWC Team Physicians, Athletic Trainers, campus health staff, or campus mental health staff Coaches and Assistant Coaches Other Athletics Staff, eg. Compliance, athletic director, sports information director Insurance Director Student Members of the Athletic Training Staff Parents or Legal Guardians Teammates Media Professional Teams and Representatives
The reason for this disclosure is to advise these individuals of the nature, diagnosis, prognosis or any treatment concerning my medical condition and any injuries or illnesses so that they may make decisions regarding my athletic ability and suitability to compete while I am a student athlete. I understand that the individuals that receive the information are not health care providers covered by federal privacy regulations, and that the information described above may be disclosed publicly and that the information will no longer be protected by those regulations.
I understand that Kentucky Wesleyan College will not receive compensation for its use/disclosure of the information. I understand that if I may refuse to check a particular box indicating that I do not want my medical information released to those particular individuals and that my refusal to not check a box will not affect my ability to obtain treatment. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment. I may inspect or copy any information used/disclosed under this authorization.
I understand that I may revoke this authorization in writing at any time by notifying, in writing, the Head Athletic Trainer but if I do, it will not have any effect on the actions KWC took in reliance on this authorization prior to receiving the revocation.
Kentucky Wesleyan College Athletic TrainingSickle Cell Trait Form 2019-2020
About Sickle Cell Trait:
Sickle Cell Trait Testing:
The NCAA mandates that all NCAA student-athletes have knowledge of their sickle cell trait status before the student participates in any intercollegiate athletics event, including strength and conditioning sessions, practices, competitions, etc.
The Kentucky Wesleyan College Athletic Department requires proof of sickle cell trait screen results for all student-athletes as part of the pre-participation physical examination.
All athletes are required do one of the following: 1. Provide a copy of birth records stating the results of the test, 2. Consent to a blood test to check for the sickle cell trait; or 3. Sign a waiver declining options 1 and 2.
All athletes must read and understand the NCAA Fact Sheet attached and sign their choice of action below.
This form must be completed before they are allowed to participate in any intercollegiate athletic event, including strength and conditioning sessions, tryouts, practices, or competitions.
Athletes who test positive for the trait will not be prohibited from participating in intercollegiate athletics.
Sickle Testing Waiver: Do not initial all three options below. Initial only the one option that applies to you.
I, , understand and acknowledge that the NCAA recommends that all Student-Athletes have knowledge of their sickle cell trait status. Additionally, I have read and fully understand the aforementioned facts and about sickle cell trait and sickle cell trait testing. Recognizing that my true physical condition is dependent upon an accurate medical history and 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 Kentucky Wesleyan College Athletic Training personnel.
I am sickle cell trait positive and will provide documentation.
I wish to be tested for Sickle Cell Trait.
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 State of Kentucky, Kentucky Wesleyan College, 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 non-compliance with the mandate of the NCAA and Kentucky Wesleyan College Department of Athletics.
Important Numbers 2019-2020
Parents please keep this information. If Orthopedic in nature we will refer to our team doctor listed below. If you are experiencing an illness, we will refer to one of the two minor emergency clinics. We have built a strong relationship with these doctors and physicians and will stay within the OHRH system. They will do their best to treat our athletes professionally and with respect.
Team Doctor One Health/Owensboro Health Regional Hospital
Owensboro Health Orthopedics 1201 Pleasant Valley RoadDr. Reid Wilson Owensboro, Kentucky 423031301 Pleasant Valley Road 270-417-2000 270-417-7940
Minor Emergency Clinics
Health Park Convenient Care Springs Urgent Care 2211 Mayfair Ave 2200 E Parrish HWY 54Owensboro, KY 42301 Owensboro, KY 42303270-688-1352 270-852-1632 Mon – Sun 8:00am – 8:00pm Mon – Fri 8:00am – 7:00pm
MRI/XRAYS Counseling Services RDI Outpatient Imaging Director of Counseling Services270-926-8171 Terri Petzold, MSW, LCSW, TCABC Kentucky Wesleyan College Admin Bldg. Room 209B 270-852-3183
Campus Counseling ServicesKentucky Wesleyan College provides mental health counseling services for all students through the Counseling Services Office located in the Administration Building Room 209B. This office is staffed by the Director of Counseling who is a Licensed Clinical Social Worker. Services are provided for a number of issues including college adjustment, stress, problem habits/behaviors, anxiety, depression, grief, eating disorders, substance use/abuse, family/personal relationship concerns and other issues related to mental health. Individual, couples and group counseling are available.Fees for these services are included in tuition costs; there is no additional charge to the student. Students may call the Counseling Services Office directly to schedule an appointment, 270-852-3183. In the event this call goes to voicemail, callers are encouraged to leave a message with contact information; the call will be returned promptly. All information shared with the counselor is considered strictly confidential. Students experiencing personal, emotional, psychological, or academic problems are encouraged to seek assistance through the Counseling Services Office.
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Document Name: Athletic Participation Form
Agree & Sign