ATHLETE'S INFORMATION



Please choose your sport

HEALTH INSURANCE INFORMATION






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Do you have a co-pay?



HEALTH INSURANCE INFORMATION

Does the policy cover athletic related injuries?

Are you/your son/daughter covered by the above policy?

Do you/your son/daughter have a prescription plan?




CLAIM AUTHORIZATION

I hereby authorize a claim to be filed on my behalf under the above insurance policies in the event an athletic injury is sustained by me/my son/daughter.

I hereby authorize Texas A&M University-Texarkana Department of Athletics to release the above information as well as release any medical information needed to process a claim on their behalf for my/son/daughter’s medical expenses with my insurance company.

I hereby authorize the payment of medical benefits, by my insurance company, be made to the physicians or supplier for services rendered.

A photocopy of this authorization shall be considered as effective and valid as the original.

My name, date of birth, and last four of my SSN entered below will serve as my signature on this electronic form. 


Please enclose a copy of the front and back of your health insurance card(s), prescription card(s), and dental card(s). 

STATEMENT OF POTENTIAL INJURY DUE TO PARTICIPATION IN INTERCOLLEGIATE ATHLETICS

The purpose of this statement is to inform each parent/guardian/student-athlete of the risk of injury while participating in intercollegiate sports practice and competition. The extent of such injuries may be irreversible and in some cases may prove to be crippling, reducing their ability to earn a living. There is even a small chance that an injury may prove to be fatal.

Athletes participating in sports such as football, soccer, and basketball (classified as collision sports) will experience many types of physical contact. Texas A&M University-Texarkana provides protective equipment. However, equipment and instruction cannot prevent all serious injuries that may result. Efforts will be made to protect the student-athlete from injury. Athletes must, however, share the responsibility and recognize the necessity for following the rules and regulations designed to make intercollegiate sports practice and competition safer and less hazardous.

There are other injuries not included, but here is a non-exclusive list of injuries a student-athlete could sustain by participating in athletics at Texas A&M University-Texarkana: head injuries resulting in coma, brain damage and/or death; spine injuries resulting in quadriplegia, paraplegia, and/or death; strains resulting in completely torn, partially torn, and/or stretched muscles or tendons; sprains resulting in completely torn, partially torn, and/or stretched ligaments; lacerations, abrasions and other flesh wounds that could result in infection; contusions; internal organ damage; loss of limb or vital organ of the body; cartilage damage in the joints of the body. By signing this document, you recognize the student-athlete assumes the risks associated with their participation in athletics and that they have been warned of the hazards inherent in sports competition. Please discuss the risks with the student-athlete before signing this form. If you have any questions, please contact the Director of Athletics to discuss your concerns.

I have read the above statement and I am aware of the inherent risks involved in athletic related activities at Texas A&M University-Texarkana.

My name, date of birth, and last four of my SSN entered below will serve as my signature on this electronic form. 



CONSENT FOR MEDICAL TREATMENT & MEDICAL INFORMATION RELEASE

Permission is hereby granted to the team/attending physician(s) and/or athletic trainer(s) to proceed with any needed medical or emergency treatment, diagnostic test, examination, rehabilitation and immunizations for the above named student-athlete. Permission is also granted to disclose any medical or personal insurance information on above student-athlete amongst any pertinent medical personnel, who may include: the Texas A&M University-Texarkana Athletic Training Staff, Athletic Administration, coaches, insurance/claims personnel, hospitals, doctor’s staff, etc. In the event of serious injury/illness, the need for major surgery, or significant accidental injury, it is understood that an attempt will be made by the team/attending physician or athletic trainer to contact one of the listed contacts in the most expeditious manner possible. If the team/attending physician or athletic trainer is unable to contact the family or emergency contact, the treatment necessary for the best interest of the student-athlete may be given. Also, the medical/health insurance that covers the student-athlete will be used as the primary insurance.

My name, date of birth, and last four of my SSN entered below will serve as my signature on this electronic form. 



INJURY/ILLNESS AGREEMENT

I understand that I must refrain from practice or play while ill or injured if so determined by the Texas A&M University-Texarkana team physician and/or staff athletic trainer. The return to play decision will be determined by the Texas A&M University-Texarkana team physician and/or staff athletic trainer. The Texas A&M University-Texarkana sports medicine staff with the recommendation of the team physician has the final authority in determining if the student-athlete is physically fit to participate in athletics at Texas A&M University-Texarkana. I am required to attend all treatment, rehabilitation and doctor appointments deemed necessary by the Texas A&M University-Texarkana sports medicine team. I accept the responsibility for reporting all injuries and illnesses that occur to me to institutional medical staff, especially all signs and symptoms of concussions.

My name, date of birth, and last four of my SSN entered below will serve as my signature on this electronic form. 



STUDENT ATHLETE FACT SHEET


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PERMANENT PARENT/GUARDIAN ADDRESS



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COLLEGE ADDRESS (Dorm & Room, Apartment, Duplex, or House)



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EMERGENCY CONTACT INFORMATION
In case of emergency, please contact (other than parent, ex. Grandparent, uncle, etc.)



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HEALTH HISTORY
This form is for your benefit. You must disclose all injuries or problems whether you consider it to have been serious or minor.

Have you ever had or currently have any of the following illness/medical issue? Please check all that apply.


Each item that you checked “Yes” to above must be fully explained below. 


Have you had any surgeries?



HEALTH HISTORY
This form is for your benefit. You must disclose all injuries or problems whether you consider it to have been serious or minor.

Have you been advised to have a surgery?




Have you ever been diagnosed with a Heart Murmur or Weak/Enlarged Heart?


Please check if you have ever experienced any of the following symptoms with exercise.



Do you have a family member(s) that have died of heart problems or unexplained reasons before the age of 50?


Have you ever had a concussion?

Have you ever had a seizure?

Do you have any non-functioning or missing any of your paired organs? (ex. Kidney, Eye, Testicle)

Have you ever been suspected of having an eating disorder?


HEALTH HISTORY
This form is for your benefit. You must disclose all injuries or problems whether you consider it to have been serious or minor.

I certify that I have made full and complete written disclosure of all past and present injuries or problems as required. I understand that failure to do so may result in loss of playing time, eligibility, and possible scholarship reduction. I understand that any costs that result in my failure to report my medical history may be my responsibility.

My name, date of birth, and last four of my SSN entered below will serve as my signature on this electronic form. 


PARENT/GUARDIAN INFORMED CONSENT AND RELEASE OF LIABILITY STATEMENT

FOR STUDENT ATHLETE'S UNDER THE AGE OF 18


as the parent/legal guardian of 


herby acknowledge that I have been fully advised on Texas A&M University-Texarkana Department of Athletics Drug Education, Testing, and Counseling Program and Procedures. I understand that as a condition of my son/daughter’s participation in intercollegiate athletics at Texas A&M-Texarkana, he/she must agree to undergo, during the academic year, one or more standardized urinalysis or any other recognized test and that my son/daughter has executed the Drug Screening Release. I hereby give my permission to the Department of Athletics at Texas A&M-Texarkana to conduct, with respect to my son/daughter, the standardized urinalysis or any other recognized test described in the Athletics Drug Education, Testing, and Counseling Program and Procedures.

My name, date of birth, and last four of my SSN entered below will serve as my signature on this electronic form. 


INFORMED CONSENT AND RELEASE OF LIABILITY STATEMENT

FOR STUDENT ATHLETE'S OVER THE AGE OF 18


herby acknowledge that I have been fully advised on Texas A&M University-Texarkana Department of Athletics Drug Education, Testing, and Counseling Program and Procedures. I understand that as a condition of my participation in intercollegiate athletics at Texas A&M-Texarkana, I must agree to undergo, during the academic year, one or more standardized urinalysis or any other recognized test and that I executed the Drug Screening Release. I hereby give my permission to the Department of Athletics at Texas A&M-Texarkana to conduct the standardized urinalysis or any other recognized test described in the Athletics Drug Education, Testing, and Counseling Program and Procedures.

My name, date of birth, and last four of my SSN entered below will serve as my signature on this electronic form.