Temple College Athletic Department

2017-2018 Student Athlete Medical Packet

Temple CollegeMike Freer- Athletic Trainer

Athletic DepartmentOffice- 254-298-8523

2600 South 1st StreetCell- 512-931-9053

Temple, Texas 76504Email-

Facility Main Number- 254-298-8522

Dear Student – Athlete (and Parents),

The Athletic Department is pleased to have you as a student athlete at Temple College, and we wish you nothing but success both academically and athletically during your time with us. Enclosed with this letter are the pre-participation medical information forms that are needed to participate in athletics at Temple College. Please thoroughly read and complete the enclosed paperwork. Athletes are required to return the completed forms to Mike Freer at Temple College prior to participation in the athletic program.

YOU WILL NOT BE PERMITTED TO PARTICIPATE UNTIL ALL INFORMATION FROM THIS PACKET HAS BEEN RECEIVED AND YOU HAVE BEEN MEDICALLY CLEARED BY A PHYSICIAN.

Please pay careful attention to the following key policies when reviewing this packet:

1-In accordance with NJCAA regulations, all prospective student-athletes must receive medical clearance (in the form of a Pre-Participation Physical) from a physician prior to participation in any intercollegiate sport activity (tryouts, practice, workouts, etc.).

  1. Each year, Temple College Athletic Department requires ALL student-athletes to provide a valid pre-participation physical exam that meets NJCAA standards.

2-A physician(s) has the final authority to medically clear a student-athlete for participation.

3-Your personal health insurance is primary for all costs related to intercollegiate athletic injuries.

4-The medical information requested by Temple College Athletic Department is in addition to, and not in place of, medical information requested of all students by Temple College Admissions Office, Financial Aid Office, and/or Housing Department.

The Temple College Athletic Department serves and supports each student-athlete, and Temple College as a whole, by working collaboratively with a variety of healthcare professionals. Together we provide the most comprehensive and evidence based healthcare practices, while maintaining the highest level of professionalism and integrity.

Athletic Director: Craig McMurtry 254-298-8529

Athletic Administrator: Alana Jones 254-298-8522

Head Men’s Basketball Coach: Kirby Johnson 254-298-8525

Head Women’s Basketball Coach: Kim Sebek 254-298-8527

Head Volleyball Coach: Jordan Pickett 254-298-8531

Head Baseball Coach: Craig McMurtry 254-298-8529

Assistant Baseball Coach: Frank Kellner 254-298-8534

Head Softball Coach: Kristen Zaleski 254-298-8528

Athletic Trainer: Mike 254-298-8523

Temple College – Athletic Department

2017-2018 Student Athlete Medical Packet

Checklist

The following checklist is intended to assist you with completion of your medical packet. ALL of the following must be completed prior to returning the medical packet. Failure to do so will result in an incomplete sports medicine packet and the student-athlete WILL NOT be permitted to participate in intercollegiate athletics at Temple College. Please bring this medical packet with you when you report to Temple College for athletics.

  • Student-Athlete Information Form
  • Insurance Information
  • Insurance Card Copy (front and back of card required)
  • Student-Athlete Medical History Information Form
  • Pre-Participation Physical Examination Form (bottom section to be completed during physical exam by a physician)
  • Physical can be completed by your personal physician or when you report to Temple College

Should you have any questions please contact Mike Freer at 254-298-8523 or via email at

Temple College – Athletic Department

2017-2018 Student Athlete Medical Packet

Student-Athlete Information

(Please print and use blue or black ink)

Last Name:______First Name:______MI:______

Date of Birth:______(MM/DD/YY)

SS#:______SID#:______

Sport:______

Temporary Address (On Campus): ______

______

City State Zip Code

Permanent Address (Off Campus): ______

______

City State Zip Code

Student-Athlete Cell Phone: ______Student-Athlete Alternate Phone: ______

Student-Athlete Email Address: ______

Emergency Contacts

Primary Contact: ______Relationship to Athlete: ______

Cell Phone: ______Alternate Phone:______

Secondary Contact:______Relationship to Athlete: ______

Cell Phone: ______Alternate Phone: ______

In an emergency, I authorize the Temple College Athletic Department and affiliated providers to contact the person(s) listed above.

Student-Athlete’s Signature: ______Date: ______

Temple College – Athletic Department

2017-2018 Student Athlete Medical Packet

Insurance Information Form

Athlete’s Name: ______Athlete’s DOB:______SS#:______

Permanent Address: ______

Street City State Zip Code

Policy Holder’s Information (policy holder/subscriber may not be the student-athlete)

Subscriber: ______Subscriber’s DOB: ______SS#:______

Home Address: ______

Street City State Zip Code

Cell Phone: ______Home Phone: ______

Employer:______

Employer Address: ______

StreetCityState Zip Code

Insurance Company: ______Insurance Company Phone #: ______

Insurance Address: ______

Street City State Zip Code

Policy/ ID #:______Group #:______

Type of Insurance: ___HMO ___PPO __Indemnity ___ Other ______Does this policy include dental? _____

Primary Care Physician:______Physician Phone #: ______

Please Check One:

___ I hereby authorize a claim to be filed on my behalf under the above group medical policy in the event an athletic injury is sustained by my son/daughter.

___ My son/daughter is NOT covered under my group insurance.

PLEASE READ CAREFULLY

  1. The Temple College Department of Intercollegiate Athletics’ accident policy which provides insurance for student-athletes for injuries occurring while participating in the play or practice of intercollegiate athletics is considered “EXCESS” or “SECONDARY” to any student-athlete before Temple College will assist with any payment of the claim. After all copayments and deductibles have been paid by the subscriber and all available benefits have been paid by the primary insurance company; the college’s athletic insurance company will consider remaining amounts based on REASONABLE and CUSTOMARY charges. Temple College does not have the option of waiving the requirement of filing with your group insurance.
  2. I hereby authorize the Temple College of Intercollegiate Athletics, hospitals and physicians connected with or provided, to furnish information to insurance carriers concerning any illness, injury and treatments and I hereby assign to the party all payments for medical services rendered to the student-athlete.
  3. I agree to supply any and all information requested by my primary insurance, and Temple College Department of Intercollegiate Athletics and their excess insurance company in a timely manner.
  4. I hereby authorize the Temple College Department of Intercollegiate Athletics and their excess insurance company to secure and inspect copies of case history records, lab reports, diagnoses, x-rays and any other data pertaining to the injury/illness I am receiving care for or previous confinements of disabilities relevant to the care of the injury/illness.
  5. I hereby authorize Temple College Athletic Trainer and/or my Coach to hospitalize and secure treatment for me for any athletic injury/illness.
  6. A photocopy of this authorization shall be deemed as effective and valid as the original.
  7. I agree to notify Temple College Athletic Department immediately upon any change in the above health insurance information. Should I fail to do so, I fully understand that I may be responsible for any and all charges incurred.
  8. I hereby certify that I have read and understand the above statements, that any and all questions have been answered to my satisfaction and that the answers provided are true, complete and correct to the best of my knowledge. It is illegal to knowingly provide false information on this form.

In the absence of the policy holder’s signature, the signature of the covered student-athlete will be acceptable.

Student-Athlete’s Signature:______Date:______

Policy Holder’s Signature: ______Date: ______

Insurance Card

Athlete’s Name:______DOB:______Sport:______

Copy of FRONT of the insurance card below

Copy of BACK of the insurance card below

  • Athlete will not be medically cleared to participate without legible copy of front and back of insurance card.
  • Should you choose not to use this exact page to provide a copy of your insurance card, please follow the above format including the student-athlete’s name, date of birth and sport at the top of the page.