ÐÏࡱá > þÿ .  Šþÿÿÿ ” • – — ˜ ™ š › œ  ž Ÿ   ¡ ¢ £ ¤ ¥ ¦ § ¨ © ª « ¬ ­ ® ¯ ° ± ² ³ ´ µ ¶ · ¸ ¹ º » ¼ ½ ¾ ¿ À Á ÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿì¥Á ø¿ 9 bjbj¶û¶û Ðw Ô‘égÔ‘ég‡e ¹ ÿÿ ÿÿ ÿÿ · j j ü ü ¸ ¸ ¸ ÿÿÿÿ Ì Ì Ì Ì ¤ p t Ì V ð ä ‚ f f f f Ú, Ú, Ú, þT U U U U U U $ ÿX ¶ µ[ ‚ $U ¥ ¸ Ú, n+ l Ú, Ú, Ú, $U ü ü f f ÉU ¤0 ¤0 ¤0 Ú, ^ ü † f ¸ f þT ¤0 Ú, þT ¤0 ¤0 Š VP ô ‚ 6 T f ÿÿÿÿ ÀÛ‡·ÜæÜ ÿÿÿÿ 8- JR " êT ßU 0 V lR ® 7\ D. 0 7\ D T T 7\ ¸ .T ¼ Ú, Ú, ¤0 Ú, Ú, Ú, Ú, Ú, $U $U t/ 0 Ú, Ú, Ú, V Ú, Ú, Ú, Ú, ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ 7\ Ú, Ú, Ú, Ú, Ú, Ú, Ú, Ú, Ú, j X  : To: All St. Catherine University First Year or Transfer Student-Athletes and Their Parents RE: Important Athletic Health Insurance Requirement for the 2026-2027 Academic Year Please Read Carefully! According to NCAA regulations, all student athletes must provide evidence of insurance that includes coverage for athletically related injuries. This is a pre-requisite for practice and competition. No student athlete will be allowed to participate in any sport until such evidence of current insurance coverage is on file with the St. Catherine University Athletic Department. Please fill out the following forms, which includes: Acknowledgement of Insurance Requirement Emergency Contact and Insurance Information Sports Participation Agreement Medical Release Form Consent to Treat Form Physical Examination Form Sickle Cell Trait – You are required to submit your Sickle Cell Status Mental Health Screening Tool Cardiac Screening In addition, you must include a photocopy of the front and backside of your insurance card. Insurance coverage must have a minimal limit of at least $90,000 and cover athletically related injuries. St. Catherine University will assume NO responsibility whatsoever for the payment of, or authorization to pay, medical expenses resulting from injuries that occur while participating in intercollegiate athletics at St. Catherine University. If you have questions regarding the terms of your coverage, you should contact your insurer immediately. Please be sure to note if there are any exclusions in your policy regarding athletic related injuries. Return to: Abby Edgar, Athletic Trainer St. Catherine University, 2004 Randolph Ave, F-18 St. Paul, MN 55105 If you have any questions regarding this requirement, please contact me at (651) 690-6730 or e-mail aeedgar@stkate.edu Sincerely, Abby Edgar, Head Athletic Trainer INCLUDEPICTURE "C:\\Users\\aeedgar\\Box\\Athletics - All Department\\Athletics logos\\Branding - Logos\\General Department Logos\\St.Kate.PurpleGold PNG.png" \* MERGEFORMATINET Sports Participation Agreement I, (Print Name of Athlete) , recognize that participating in the sport of (Name of Sport) , presents risk of injury. I am voluntarily participating in the above-mentioned sport, with the understanding that there is a possibility of injury. In consideration of the acceptance of this form and being allowed to participate in sports, I waive and release any and all rights and claims for damages I may have against St. Catherine University, or its respective representatives, executors, administrators and/or assignees from any and all personal injuries and property damage which may be sustained and suffered by me arising out of my association with or entry in the above mentioned sport, including my traveling with or participating in, and returning to St. Catherine for myself, my heirs, executors and administrators. I further agree that I understand that many of the activities of such intercollegiate sports involve substantial risk of injury. I have secured adequate insurance protection. I agree not to sue St. Catherine University or any of its administrators, assignees, officers, agetns, and/or employees for injuries arising out of participation in this sport. If the undersigned is married and/or a minor, then the signature of the spouse, parent or guardian appearing in the space below signifies acceptance by said spouse, parent, or guardian that the terms and conditions of this agreement will be binding upon them, and will constitute a release by them of any and all claims, demands, and causes of action whatsoever which they or any of them may have against St. Catherine University, its assigns, successors, officers, agents, or employees as a result of the undersigned student’s participation in the activities described. ____________________________ _________ __________________ Signature Date Sport(s) ______________________________ Signature of Parent/Guardian (if student athlete is a minor) Please include a photocopy of both sides of your insurance card. You should keep a copy of this document for your records. St. Catherine University Athletic Department Acknowledgement of Insurance Requirement I, (Parent/Guardian Name, Please Print) , as parent, guardian or legal representative, attest that (Student-Athlete name, Please Print) has insurance coverage under a current, in force insurance policy for injuries that occur while she is participating in intercollegiate athletics. If there is a material change in coverage or expiration of coverage, I agree to notify St. Catherine University of this development and update the Insurance Information I have on file with St. Catherine University. I understand and agree the St. Catherine University 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 St. Catherine University. I have read and agree to comply with the provisions of the Acknowledgement of Insurance Requirements. (Parent/Guardian Signature) / (Date) (Student Athlete Signature) / (Date) Name________________________________________________ Sport_____________________________ Phone Number _________________ Date of Birth_______/_______/______ Student Identification Number______________________________ Academic Year__________________Emergency Contact Information Name(s) ________________________________________________________________________________________________________________ Address_______________________________________________________________________________________________________________ City___________________________________ State_____________________________________ Zip Code____________________________ Home Phone Number__________________________________________ Work/Cell Phone Number________________________________________Insurance Information Policy Holder Name___________________________________________________ Home Phone Number_________________________________ Relationship to Student-Athlete__________________________________________ Work Phone Number__________________________________ Address_________________________________________________________________________________________________________________ City___________________________________ State_____________________________________ Zip Code_____________________________Insurance Company Name__________________________________________________________________________________________________ Insurance Company Address________________________________________________________________________________________________ Group #__________________________________________________ ID #__________________________________________________________ Effective Date of Policy______________________________________ Expiration Date_________________________________________________ Policy Limit____________________________ Policy Deductible________________________ Policy Co-Pay______________________________ Does the policy cover athletically related injuries?________________________________________________________________________________ Primary Physician_________________________________________________________________________________________________________ Name of Clinic______________________________________________________ Clinic Phone Number___________________________________ Is it necessary for the student to receive medical services from a certain provider or network of providers (HMO/PPO)? Yes No If yes, who is the provider the student is required to see?____________________________________________ INCLUDEPICTURE "C:\\Users\\aeedgar\\Box\\Athletics - All Department\\Athletics logos\\Branding - Logos\\General Department Logos\\St.Kate.PurpleGold PNG.png" \* MERGEFORMATINET Medical Information Release Form (HIPAA) Since April 14th, 2003 the Health Insurance Portability and Accountability Act has been in affect across the county for the facilities that use health care providers. There are three parts to this act. The first rule is the “Transaction Rule,” intended to standardize procedures, codes, and electronic billing format. The second rule is the “Security Rule.” This rule is designed to secure personally identifiable health care information being transmitted electronically. The third rule is the “Privacy Rule.” The privacy rule creates national standards to protect individuals’ personal health information and gives patients increased access to their medical records. The way this affects St. Catherine University student-athletes is the various methods of documentation and communication, which are used in the athletic training room and with coaches, team physicians, and physical therapists. The following signature will authorize the certified athletic trainer, team physicians, and physical therapist to communicate and view medical records pertaining to health-related issues of the student-athlete. The following methods of communication and injury documentation will be used: Oral and written communication regarding health issues between the athletic trainer, team physicians, physical therapists, coaching staff, and the Health and Wellness Center at St. Catherine University. Oral and written communication regarding health issues between athletic trainer and coaching staff. Oral and written communication regarding health issues between the athletic trainer and athletic department and St. Catherine University administration. Oral and written communication regarding health issues between the athletic trainer and the athletes’ parents (per athlete’s consent and require, if they are not a minor) Oral and written communication regarding health issues between the athletic trainer and the O’Neil Center, as needed for academic accommodations. Written documentation regarding injuries and injury treatments (i.e. treatment sheet and injury reports). Written returning-athlete and first-year athlete forms submitted to the athletic trainer and filed at the start of each sporting season. I have read and understand the means of communication and documentation that will take place in the athletic training room regarding my health history and any injury information that may develop because of my involvement in athletics at St. Catherine University. By signing I authorize the release of information to the athletic training staff at St. Catherine University. ____________________________ _________ __________________ Signature Date Sport(s) ______________________________ Signature of Parent/Guardian (if student athlete is a minor) INCLUDEPICTURE "C:\\Users\\aeedgar\\Box\\Athletics - All Department\\Athletics logos\\Branding - Logos\\General Department Logos\\St.Kate.PurpleGold PNG.png" \* MERGEFORMATINET INCLUDEPICTURE "C:\\Users\\aeedgar\\Box\\Athletics - All Department\\Athletics logos\\Branding - Logos\\General Department Logos\\St.Kate.PurpleGold PNG.png" \* MERGEFORMATINET Consent to Treat Form I, (Print Name of Athlete) , I authorize the St. Catherine University Sports Medicine Program and its affiliated or contracted healthcare providers, including physicians, athletic trainers, physical therapists, and other licensed healthcare professionals employed by or contracted with St. Catherine University or its partnering healthcare organization to perform medical evaluations, assessments, diagnosis, treatments, rehabilitation services, dietary services, emergency care, and referrals reasonably related to my athletic participation and related activities. I understand and acknowledge that certain healthcare service may be provided by healthcare professionals who are not employees of St. Catherine University, but who instead are employed by, affiliated with, or contracted through independent healthcare organizations partnering with St. Catherine University to provide sports medicine and related healthcare services. ____________________________ _________ __________________ Signature Date Sport(s) ______________________________ Signature of Parent/Guardian (if student athlete is a minor) St. Catherine University Medical History – To be completed by Student Athlete or Parent Please Complete Using Blue or Black Ink Only Name: _____________________________________ Date: ____________________ Do you have any on-going health issues such as: ____ Arthritis ____ Cardiac Problems ____Skipped or Missed Periods ____ Asthma ____ Diabetes ____ Panic Attacks/Phobias ____ Cancer ____ Migraines/Headaches/Concussions ____ Skin Condition(s) 2. Do you wear Contact? ____ Yes ____ No 3. Do you use an inhaler? ____ Yes ____ No 4. Are you double-jointed? ____ Yes ____ No 5. Do you use protective equipment? ____ Yes ____ No Explain:________________________ 6. Are you missing any organs? ____ Yes ____ No Explain: ________________________ 7. Have you ever been hospitalized? ____ Yes ____ No Explain: ________________________________________________________________________________________ 8. Have you ever had surgery? ____ Yes ____ No Explain: Have you ever sprained, strained, dislocated, fractured, had repeated swelling, or any other injury of any bones or joints? Please describe injury, side affected, and give dates Description Dates Head ______________________________________________________________________________________ Neck _______________________________________________________________________________ Chest ______________________________________________________________________________________ Shoulder ___________________________________________________________________________________ Elbow _____________________________________________________________________________________ Arm _______________________________________________________________________________________ Hand ______________________________________________________________________________________ Back _______________________________________________________________________________________ Hip ________________________________________________________________________________________ Thigh ______________________________________________________________________________________ Knee ______________________________________________________________________________________ Shin _______________________________________________________________________________________ Calf _______________________________________________________________________________________ Ankle ______________________________________________________________________________________ Foot _______________________________________________________________________________________ 11. Have any blood relatives of yours died of a heart condition before age 50? ____Yes____ No 12. Have you ever been denied or restricted from participation for any reason? ____Yes____ No If so, please explain? ___________________________________________________________ INCLUDEPICTURE "C:\\Users\\aeedgar\\Box\\Athletics - All Department\\Athletics logos\\Branding - Logos\\General Department Logos\\St.Kate.PurpleGold PNG.png" \* MERGEFORMATINET Sickle Cell Trait Testing 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 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 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 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. 17.1.6.4.1 Confirmation of Sickle Cell Trait Status. An institution shall confirm the sickle cell trait status of student-athletes, before participation in intercollegiate athletics in one of the following manners: (a) Documentation. The student-athlete may provide documented results of a sickle cell solubility test administered prior to participation; or (b) Pending Documentation. A student-athlete who has taken a sickle cell solubility test but whose results are not yet confirmed, may participate provided the student-athlete engages in mandatory education as set forth in Bylaw 17.1.6.4.1.1 and receives appropriate precautions as set forth by the institution You are now required to have your sickle cell trait status on file prior to participation. This is completed by a Sickle Cell Solubility Test administered by your Health Care Provider. This needs to be completed prior to participation. You can check with your HealthCare Provider to see if they have your Sickle Cell Trait status on file. They may have prior record of your status which you can submit to fulfill this requirement. St. Catherine University Physical Examination – To be completed by Physician Name (Last, First, Mi):Birthdate: MEDICAL EXAMINATION: BP:________ P: ________ Height(Inches):________ Current Prescriptions: ___________________________ R: ________ T: ________ Weight: ________ Allergies: ___________________________________________ PE: Normal AbnormalPE: Normal AbnormalGeneral Appearance oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ A b d o m e n : oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ O r g a n s oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ A f f e c t oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ T e n d e r oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S k i n oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ H e r n i a oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ H E E N T P e l v i c F e m a l e ( o p t i o n a l ) H e a d oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ P a p D o n e oð ðy e s oð ðn o _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ E y e s oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ V a g i n a oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ P E R R L A C e r v i x oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ F u n d i oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ U t e r u s oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ E a r s oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ A d n e x a e oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ N o s e oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ M o u t h oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ T h r o a t oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ N e c k : M u s c u l o s k e l a t a l S c r e e n : B r u i t s oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ N e c k oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ N o d e s oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S h o u l d e r oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ T h y r o i d oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ E l b o w oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ L u n g s oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ W r i s t / H a n d s oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ B r e a s t s ( o p t i o n a l ) B a c k oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ P a l p a l l o n oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ H i p oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ N i p p l e s oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Q u a d / H a m oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ A x i l l a r y N o d e s oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ K n e e oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ H e a r t : A n k l e oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ R h y t h m oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ F e e t / H e e l / T o e oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ M u r m u r oð oð _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ N e u r o : oð oð L A B : S i c k l e C e l l R e s u l t s ( i f n e e d e d ) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ A S S E S S M E N T : G e n e r a l H e a l t h : oð ðE x c e l l e n t oð ðG o o d oð ðF a i r oð ðP o o r C l e a r e d f o r p a r t i c i p a t i o n i n : ðoð ðC o n t a c t s p o r t s w i t h o u t r e s t r i c t i o n s oð ðC l e a r e d w i t h R e s t r i c t i o n _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ oð ðN o t C l e a r e d M a y p a r t i c i p a t e i n N C A A s p o r t s , c l u b s p o r t s , i n t r a m u r a l s , P E ? oð ðY E S oð ðN O P L A N : E x a m i n e r s c o m m e n t s / o t h e r r e c o m m e n d a t i o n s : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a t e o f P h y s i c a l E x a m i n a t i o n _ _ _ _ _ / _ _ _ _ _ / _ _ _ _ _ H e a l t h C a r e P r o v i d e r ( P l e a s e P r i n t ) H e a l t h Care Provider SignatureAddressCityStateZip CodePhone Number INCLUDEPICTURE "C:\\Users\\aeedgar\\Box\\Athletics - All Department\\Athletics logos\\Branding - Logos\\General Department Logos\\St.Kate.PurpleGold PNG.png" \* MERGEFORMATINET The 14-Element Cardiovascular Screening Checklist for Congenital and Genetic Heart Disease: Personal history: Chest pain/discomfort/tightness/pressure related to exertion Unexplained syncope/near-syncope* Excessive exertional and unexplained dyspnea/fatigue or palpitations, associated with exercise Prior recognition of a heart murmur Elevated systemic blood pressure Prior restriction from participation in sports Prior testing for the heart, ordered by a physician Family history: Premature death (sudden and unexpected, or otherwise) before age 50 attribut a b l e t o h e a r t d i s e a s e i n e"1 r e l a t i v e D i s a b i l i t y f r o m h e a r t d i s e a s e i n c l o s e r e l a t i v e <