new student-athlete physical forms - Centenary College of Louisiana ...

Centenary College of Louisiana
Athletic Training
Dear Athletes and Parent/Guardian,
Centenary College is pleased to have you join us as a participant in the Ladies and Gents
athletic program. Centenary College is concerned with the health and well-being of all of
our athletes. The Athletic Training Staff is responsible for the supervision of health care
for all athletes, including prevention, evaluation, treatment, and rehabilitation of injuries
sustained during intercollegiate practices and games.
When a student athlete is injured during a practice or game, they are evaluated by the
Athletic Training Staff. Initial treatment is administered and, if necessary, the athlete is
referred to a family practitioner, orthopedic surgeon, or other medical personnel. Athletes
desiring medical attention other than that provided by Centenary College Athletic
Training Staff for injuries directly related to sponsored practice or competition may do so
with clearance from the attending Athletic Trainer (and their Parent/Guardian if under 18
years of age).
Injuries or medical conditions not related to Coach sanctioned, in-season practice or
competition are the responsibility of the student athlete or family. General illness,
physical education classes, or injuries that occur outside of the student athlete’s sport are
the student athlete’s responsibility. The student athlete may, and is encouraged to receive
medical care through the attending Athletic Trainer, but is still responsible for any
medical expenses incurred.
Each form in this packet includes instructions and information specific to each
form. All forms must be fully completed and returned no later than ten (10) days
prior to the start of the fall semester. Athletes will not be allowed to practice or
participate in sports activities until all of the enclosed paperwork is returned and
insurance coverage has been verified by the Centenary staff.
Return packets to:
Centenary College of Louisiana
Athletic Training Room
2911 Centenary Blvd
PO Box 41188
Shreveport, LA 71134-1188
If you have any questions concerning Centenary College’s policies or any of the forms
please do not hesitate to contact us at (318) 869-5093.
Stephanie Culbertson, ATC, LAT
Head Athletic Trainer

Centenary College of Louisiana
Athletic Insurance Procedures
All Athletes are required to have medical insurance coverage
o Under Parent/Guardian policy, or
o An individual policy
All Athletes are required to provide proof of insurance
o A copy of the Athlete’s insurance card, or
o A copy of a medical I.D. card
Until proof of insurance is provided and verified by Centenary College, Athletes
will not be allowed to participate in any athletic activities.
Centenary College insurance is secondary to the Athlete’s primary insurance
coverage.
Centenary College is not responsible for any medical expenses for any Athlete not
covered by primary medical insurance. If your primary medical insurance lapses,
the secondary insurance will not cover any expenses.
The Athlete (Parent/Guardian) is responsible for all deductibles, co-pays, coinsurance,
and/or out- of-pocket expenses.
Remember: All athletes must have their health insurance/policy verified and cleared
BEFORE they can participate in any athletic activities, including practice.

Centenary College of Louisiana
Form Information and Instructions
Form A- Emergency Contact Information
In the event that an athlete required emergency care, it is essential that Centenary College
staff have emergency contact information in order to respond quickly and effectively.
Form B- Medical History
In order to assess each athlete’s physical ability to participate in Centenary College
athletic programs accurate information regarding your physical condition is essential.
Medical abnormalities existing prior to Centenary College athletic competition are the
responsibility of the Student Athlete and/or Parent/Guardians. The Centenary College
Medical Director/Team Physician may disqualify the Athlete from participation in
Centenary College intercollegiate athletes due to pre-existing conditions. A Preparticipation
Physical Exam must be completed for all incoming athletes before the first
team activity.
Please carefully read and completely answer each question on Form B. If you need to
provide additional information please attach a separate sheet. Intentional falsification of
information may be grounds for immediate disqualification and/or disciplinary action up
to and including removal from the athletic programs.
Please be sure to complete all questions, and be sure to sign and date the form. Please be
very specific and including information regarding allergies, supplement use or medicines.
If the athlete is 18 years of age or older the athlete must sign the forms. If not, a
Parent/Guardian must sign all forms as well as the athlete.
Form C- Medical Insurance Information
In order to practice or participate in intercollegiate sports at Centenary College, each
athlete must have insurance, which does not exclude athletic activities.
The information required on this form is essential for Centenary College staff to verify
medical coverage. Unless all sections are fully completed, the athletes cannot and will not
be cleared to participate in athletic activities.
Centenary College requires that all student athletes provide proof of medical insurance
coverage. The college’s accidental medical insurance is a “secondary medical plan”,
meaning that any medical expenses for athletic injuries must first be submitted to the
athlete’s primary insurance provider for payment. All deductibles, co-payments, coinsurance,
etc. are the responsibility of the athlete or parent/guardian.

Depending upon the insurance plan, bills will wither be directly submitted to the athlete’s
primary insurance provider or it may be sent to the policyholder for submission to the
primary insurance provider. It is important to remember that in cases where the athlete is
covered under a PPO or HMO, the athlete must work within their system for medical
treatment; therefore, required approvals must be obtained prior to seeking treatment
outside the system.
Important Notes:
The accident insurance provided by Centenary College is secondary to your
primary medical insurance coverage. Therefore, it is imperative that your
primary insurance policy not be allowed to expire.
You are required to provide notice to the Athletics Department immediately
if your primary insurance policy changes (i.e. expires, changes to a different
provider, etc.)
Upon completion of Form C, please be sure to sign and date the form- and be
sure to include a copy of your insurance card (or medical I.D. card)
Form D- Assumption of Risk
In the event of an injury, it may be necessary to obtain the athlete’s medical files, release
information that Centenary College possesses relative to you, or provide treatment.
Therefore, you must complete and sign the attached Consent forms.
Medical information will only be obtained or released on an “as needed” basis. All
information will be treated confidentially at all times and will only be shared with the
individuals with a need to know.
Please read the form and then sign and date each of the three sections. The athlete must
sign the form and the parent/guardian must sign if the athlete is under 18 years of
age.
Form E- Authorization to Release of Information
Signing this form will authorize Centenary College to release any and all information
concerning an athlete and their records to professional teams, agents, scouts, etc. You
may refuse to sign if you so choose. If you choose to sign please read the form
thoroughly before signing and dating.
Form F- NCAA Sickle Cell Trait Testing Waiver
This form allows the student athlete to request sickle cell testing or waive any testing or
institutional liability for not testing. If the student-athlete is under the age of 18 years of
age the athlete must have a parent/guardian sign this form.

Form G- University Drug Testing Agreement
Signing this form, the student-athlete agrees to institutional drug testing as means to
provide for their safety and well-being. All Centenary College student-athletes must
participate in this program.
Form H- Informed Consent for Medical Treatment
Signing this form authorizes Centenary College’s Athletic Training staff to assess, treat,
and rehabilitate any injury that results in athletic participation at Centenary College. This
form also grants permission for the Athletic Training staff to refer the student athlete to
the appropriate medical personnel for any injury or illness.
Secondly this form states that it is the athlete’s responsibility to report any injury, suspect
of a concussion, or illness to the Athletic Training staff as soon as possible.
If the athlete is under the age of 18 years of age the parent/guardian must also sign this
form.

Form A
Centenary College of Louisiana
Emergency Contact Information
Year of Eligibility: (Circle one) Freshman Sophomore Junior Senior
First Name: __________________ Last Name: ___________________ Date of Birth: _____/_____/_____
Social Security Number: _______-______-________ Age: ____ Sport: ____________
Home Address: ____________________________
Campus/Local Address: _______________________
City, State: ________________________________ City, State: ________________________________
Zip: ____________________
Home Phone: _______-________-___________
Cell Phone: _______-_________-__________
Zip: _______________________
Local Phone: _______-_________-___________
Email: _____________________________________
Parent Guardian Contact Information:
Father/Guardian’s Name: ____________________________
Home Address: __________________________________
City, State, Zip: __________________________________
Cell Phone: ____________________________________
Home Phone: _____________________________________
Work Phone: ______________________________________
Email: __________________________________________
Mother/Guardian’s Name: ____________________________
Home Address: __________________________________
City, State, Zip: __________________________________
Cell Phone: ____________________________________
Home Phone: _____________________________________
Work Phone: ______________________________________
Email: __________________________________________
EMERGENCY CONTACT (Closest relative not living with parents/guardians) :
Name: _______________________________
Cell Phone: _____________________________
Relationship to Athlete: __________________________
Home Phone: ______________________

Form B
Centenary College of Louisiana
Medical History Form
Demographics:
Name: ________________________________ Sport: ___________ Pos.: _______________
Date: ___________ Age: _______________ Birth Date: ____/____/____
Family History:
Has anyone in your immediate family had any of the following: Please circle yes or no.
Heart Disease Yes No Diabetes Yes No
High Blood Pressure Yes No Cancer Yes No
Stroke Yes No Tuberculosis Yes No
Sudden Death (before 50) Yes No Asthma Yes No
Epilepsy Yes No Gout Yes No
Migraine Headaches Yes No Marfan’s Syndrome Yes No
Eating Disorder Yes No Sickle Cell Yes No
Personal History:
1. Have you ever been hospitalized? Yes No
Have you ever had surgery? Yes No
Are you presently under a doctor’s care? Yes No
Please explain and give dates for all “Yes” answers: ___________________________________
_____________________________________________________________________________
2. Please list any medications you are currently taking and for what conditions. _______________
_____________________________________________________________________________
3. Please list any known allergies. ___________________________________________________
____________________________________________________________________________
4. Have you ever had a head injury / concussion? Yes No
Have you ever been knocked out or unconscious? Yes No
Have you ever had a seizure, “fit”, or epilepsy? Yes No
Have you ever had a stinger, burner, or pinched nerve? Yes No
Do you have recurring headaches or migraines? Yes No
Pleas explain and give dates of “Yes” answers: _______________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
5. Have you ever had the chicken pox? Yes No
If yes, at what age? _________
6. Have you ever had the mumps or measles? Yes No
7. Do you have a history of asthma? Yes No
8. Are you missing an eye, kidney, lung, or testicle? Yes No
9. Do you have any problems with your eyes or vision? Yes No
10. Have you ever had any other medical problems (mononucleosis,
diabetes, anemia)? Yes No
11. Have you ever taken any supplements for improved performance? Yes No
12. Are you presently taking any supplements for diet or performance?
(creatine, protein, etc.)? Yes No
If Yes then what substance? ___________________________

13. Do you have any trouble breathing or do you cough during or after
practice? Yes No
14. Have you ever had heat cramps, heat illness, or muscle cramps? Yes No
15. Do you have any skin problems (itching, rashes, acne)? Yes No
Explain all “Yes” answers for questions 5 – 15: _________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
16. What is the lowest weight you have been at in the last year _____,
Highest_____? What is your ideal weight _______?
17. If female, what is the date of your last menstrual cycle _________________?
18. Have you ever passed out during or after exercise? Yes No
Have you ever been dizzy during or after exercise? Yes No
Have you ever had chest pain during or after exercise? Yes No
Have you ever had high blood pressure? Yes No
Have you ever been told you have a heart murmur? Yes No
Have you ever had racing of you heart or a skipped heart beat? Yes No
Has anyone in your family died of heart problems or sudden
death before the age of 50? Yes No
Have you ever had an EKG or echocardiogram? Yes No
Explain all “Yes” answers for question 18: _____________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
18. Have you ever sprained / strained, dislocated, fractured, or had repeated swelling or other injury
of any bones or joints? Explain any “Yes” answers.
Head/Neck Yes No __________________________________________________
Shoulder Yes No __________________________________________________
Elbow & arm Yes No __________________________________________________
Wrist, hand & fingers Yes No __________________________________________________
Back Yes No __________________________________________________
Hip / Thigh Yes No __________________________________________________
Knee Yes No __________________________________________________
Shin/Calf Yes No __________________________________________________
Ankle, foot, toes Yes No __________________________________________________
Please sign:
I hereby state that, to the best of my knowledge, my answers to the above questions are correct.
__________________________________________________________________________
Athlete’s Signature
Date Signed
__________________________________________________________________________
Parent’s Signature, if under 18 years of age
Date Signed

Form C
Centenary College Sports Medicine
Insurance Information
Year of Eligibility: (Circle one) Freshman Sophomore Junior Senior
Athlete’s Name: ___________________________ Social Security No.:_____________________
Sex: ___________ Date of Birth: ________________ Sport: _____________________
Primary Insurance Plan: Father’s Mother’s Self
Policy Holder: ___________________ Relationship to Athlete: _____________________
Social Security No.:_________________ DOB: _______ Insurance Company: ___________________
Insurance Type: (Check One) HMO PPO POS Other:__________________
Policy Number ID: _________________________ Group#/Plan: _____________________
Ins. Company Address: ________________________ City, State, And Zip: ______________________
Coverage effective dates: __________________ Insurance Phone: ______________________
Is Preauthorization necessary for medical/diagnostic services? Yes No Phone: __________________
Does this insurance cover athletic related injuries?  Yes  No
______________________________________________________________________________________
PLEASE READ CAREFULLY!
Centenary College Department of Athletics’ accident policy provides insurance for student-athletes with
injuries occurring only when participating in the play or practice of intercollegiate athletics. Centenary
College accident policy is considered “EXCESS” or “SECONDARY” to any other collectible group
insurance benefits. Therefore, any claims for benefits must first be filed with the group insurance company
providing coverage. Only after all available benefits have been exhausted will the Centenary College
insurance carrier consider payment for any remaining balances.
I hereby authorize Centenary College, hospitals, & physicians connected with or provided, to
furnish information to insurance carriers concerning any illness, injury, & treatments & I hereby
assign to the party all payments for medical services rendered to the student-athlete.
I agree to supply any & all information requested by my primary insurance, Centenary College &
their excess insurance company in a timely manner.
I hereby authorize Centenary College and their excess insurance company to secure & inspect
copies of case history records, lab, reports, diagnoses, x-rays, & 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.
I hereby authorize the Centenary College Sports Medicine Department and/or my coach to
hospitalize & secure treatment for me for any athletic injury/illness. (Must be cosigned by
parent/guardian if student athlete is under 18 years of age)
A photo static copy of this authorization shall be deemed as effective & valid as the original.
I agree to notify the Centenary College Sports Medicine Department immediately upon any
change in the above health insurance information. If I fail to do so, I fully understand that I will
be responsible for any & all charges.
I hereby certify that I have read & understand the above statements, that any & all questions have
been answered to my satisfaction, & that the answers provided are true, complete, & correct to the
best of my knowledge.
Student Athlete’s Signature: ___________________________________________Date______________
Parent/Guardian’s Signature: __________________________________________ Date: ______________

The Athletic Training Staff must have a copy each year of insurance cards. Please make a
copy of each card applicable below.
Health Insurance Card
Front
Health Insurance Card
Back
Pharmacy Card
Front
(If different from above)
Pharmacy Card
Back
(If different from above)
Dental Insurance Card
Front
Dental Insurance Card
Back

Form D
Centenary College of Louisiana
Warning, Release, Assumption of Risk
I am aware that playing or practicing to play and conditioning for competitive athletics could be a dangerous
activity involving many risks of injury. I understand that the dangers and risks of playing or practicing to play
and conditioning for competitive athletics include, but are not limited to death, serious neck and spinal injury
(spinal cord or vertebral bodies) which may result in complete or partial paralysis, brain damage, serious injury
to virtually all internal organs, serious injury to virtually all bones, joints, ligaments, muscles, tendons and other
aspects of the muscular skeletal system and serious injury or impairment to other aspects of my body, general
health and well-being, and/or other acts of God. I understand that the dangers and risks of playing or practicing
to play and conditioning for competitive athletics may result not only in serious injury but in a serious
impairment of my future abilities to earn a living, to engage in other business, social and recreational activities,
and generally enjoy life.
Because of the dangers of competitive athletics, I recognize the importance of following coaches’ instructions
regarding playing techniques, training, and other team rules, etc., and to agree to obey instructions.
In consideration of Centenary College providing medical services and in permitting me to play competitive
athletics and to engage in all activities related to the team, including but not limited to practicing or playing
competitive athletics and for other good and valuable consideration, I hereby assume all the risks associated
with competitive athletics and agree to hold Centenary College, and their respective employees,
representatives, athletic trainers, team physicians, equipment managers and volunteers harmless from any and
all liability, actions, causes of action, debts, claims or demand of any kind and nature whatsoever which may
arise by or in connection with my participation in any activities related to the Centenary College Athletics. The
terms hereof serve as a release and assumption of risk for my heirs, estate, executor, administrator, assignees,
and for all members of my family.
This release remains valid until a written revocation, signed by the undersigned, is delivered to duly
authorized representatives of Centenary College.
____________________________________________________________________________________
Signature of Student-Athlete Sport Date
____________________________________________________________________________________
Witness
Date
____________________________________________________________________________________
Signature of Parent(s) or Legal Guardian(s)*
Date
*Necessary if Student-Athlete is under the age of 18

Form E
STUDENT-ATHLETE AUTHORIZATION FOR
RELEASE OF INFORMATION TO MEDIA
I, , HEREBY AUTHORIZE AND REQUEST the
Student- Athlete Print Name
Centenary College Board of Trustees, the Centenary College Athletics and Sports Medicine
Departments, and their duly authorized officers, employees and agents (including coaches, athletic
trainers, physicians, and physical therapists) to furnish TO SPORTS INFORMATION AND/OR
JOURNALISTS AND/OR OTHER MEDIA OUTLETS any and all information concerning or having
a bearing on my participation in athletics at Centenary College. This authorization shall include,
but is not limited to, any and all information within their knowledge, or contained in any records
under their supervision or control concerning my physical condition, illnesses, injuries, and any
treatment, hospitalization, surgery, examinations, diagnostic testing, and otherwise, and to make
such reports concerning myself to such persons or organizations as they may request.
This authorization DOES NOT apply to the release of any records pertaining to psychiatric,
psychological or psychotherapeutic services.
I understand that a record will be kept of all individuals requesting information under this
Authorization and the date of the request. This information is normally confidential and except as
provided in this Authorization will not be otherwise released by the parties in charge of the
information.
This Authorization remains valid for [check one]:
one (1) year following the date I sign below; or
to this date .
I understand that I may revoke this authorization by providing a written revocation of authorization
to the Program Coordinator that specifically mentions release of information to MEDIA, including
journalists, reporters, sports information, or any other media outlet representatives. I understand
that a revocation is not effective to the extent that Centenary College has relied on this
authorization to use or disclose any information about me.
I hereby fully release and discharge Centenary College Board of Trustees and all its successors,
assigns, trustees, officers, agents, and employees from any and all claims, demands, and causes
of action whatsoever in connection with or in any way related to or arising out of the disclosure of
information under the terms of this Authorization.
Student-Athlete Signature sport Date
Witness Signature
Witness Print Name

Form F
Centenary College
NCAA 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- greater than three million Americans have Sickle Cell. Although Sickle cell trait is most
predominant in African-Americans and those of Mediterranean, Middle Eastern, Caribbean, and South and Central
American ancestry, persons of all races and ancestry may test positive for the 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.
Likely sickling settings include timed runs, all out exertion of any type for 2-3 continuous minutes without a rest period,
intense drills and other spurts of exercise after prolonged conditioning exercises, and other extreme conditioning sessions.
Common signs and symptoms of a sickle cell emergency include, but are not limited to: increased pain and weakness in the
working muscles (especially the legs, buttocks, and/or low back); cramping type pain of muscles; soft, flaccid muscle tone;
and/or immediate symptoms with no early warning signs.
Education and precautions can prevent sickle cell crises in athletes with sickle cell trait. These include adjusting exercise
for the environmental temperature, emphasizing hydration, controlling asthma, no exercise if a sickle trait athlete is ill and
modifying exercise upon exposure to new altitude.
No sickle trait athlete is ever disqualified form participating in sports.
Sickle Cell Trait Testing Policy
According to the NCAA Mandate for 2013-2014 Academic year and effective August 1, 2013, the student-athlete must select
one of the following three options prior to participating in an athletic activity:
_____Provide appropriate documentation of Sickle Cell Trait test results. The student-athlete or parent/guardian may
obtain this documentation from their family physician/birth physician. (Use Sickle Cell Verification Form). If the studentathlete
is unable to obtain this information, a new blood screening may be necessary.
_____Pending documentation is acceptable provided the student-athlete has taken the Sickle Cell Trait test, but has yet to
receive the test results. This option requires that the student-athlete attend a mandatory educational class on the risks
involved in Sickle Cell Trait and student-athletes.
_____ Declining to confirm the student-athletes Sickle Cell Trait status and/or provide Centenary College’s Sports
Medicine Staff with appropriate paperwork results. The student-athlete must understand by selecting this option he/she will
participate in a mandatory education class approved only by the Sports Medicine Staff. Please read the statement below
and sign accordingly.
NOTE: ONLY SIGN BELOW IF THE THIRD OPTION IS SELCTED.
I, ___________________________________________, hereby agree to attend a mandatory educational class in accordance with the
NCAA Mandate for Sickle Cell Verification. I understand that by signing below I am aware that I am declining confirmation of my
Sickle Cell Trait test status.
__________________________________________________
Student-Athlete Signature (Guardian Signature if under 18)
__________________________________________________
Witness
_____________________________
Date
______________________________
Date
I understand the NCAA Mandate for 2013-2014 Academic Year requires that I must provide Centenary College’s Sports Medicine
Staff with the appropriate paperwork, and I am willing to provide such paperwork to enable me to participate in Intercollegiate
Athletics at Centenary College of Louisiana.
____________________________________________________
Student-Athlete Signature (Guardian Signature if under 18)
____________________________________________________
Witness
________________________________
Date
________________________________
Date

Centenary College of Louisiana
Sickle Cell Trait Status Verification Form
Name: ________________________________ Sport: _____________________________________
Date of Birth: ________________________________ Year of Eligibility: 1 2 3 4
Student I.D. #: _______________________________ Students Phone #: ____________________________
Local Address: ________________________________________________________________________________
Please list the date of the Sickle Cell Trait testing:
___________________
Please circle the result of the Sickle Cell Trait test: Negative Positive
Are there any restrictions to participation:
No restrictions _______________
Restricted to _____________________________________________
_____________________________________________
I verify that the above named individual has been tested for Sickle Cell Trait.
Physician’s signature: _________________________________________
Date: _____________________
Printed Physician’s Name and Address:
_________________________________________________
_________________________________________________
_________________________________________________
SIGN AND RETURN ALL FORMS TO THE CENTENARY COLLEGE SPORTS MEDICINE
DEPARTMENT BY AUGUST 1 ST . 2911 CENTENARY BLVD. SHREVEPORT, LA 71104
FAX #318-841-7254

Form G
Centenary College Sports Medicine
Drug Testing Consent Statement
I certify by my signature below that:
I recognize and understand that I could be asked to provide a urine sample for drug analysis. I
consent to any such testing conducted as part of the College’s Policy on Drug/Substance Abuse,
Supplements, and Random/Selective Drug Testing, and agree if I refuse to take any such test, it
will be considered a positive test.
I understand the University will take every precaution to maintain the confidentiality of all
matters related to the test(s) to be performed pursuant to this policy. I do realize and consent to a
third party testing company to share my results with Centenary College.
I must report to the Centenary College Athletic Training Staff and the Team Physicians of any
and all medications and supplements which I may take form time to time, either under
prescription from a physician or self-administered.
I recognize this information is necessary to assist my Team Physician and the Athletic Training
Staff in providing me with the best medical care. Thus, I give my permission to the Centenary
College Team Physician and the Athletic Training Staff to release this information to the drug
testing lab and NCAA if needed.
I understand that I must comply fully with the College’s Policy on Drug/Substance Abuse,
Supplements, and Random/Selective Drug Testing to participate in Division III Intercollegiate
Athletics at Centenary College.
I understand that the College’s counseling services are available to me should I have a difficult
time with alcohol, drugs, or any other personal matter.
Athlete’s Printed Name: _________________________________________
Athlete’s Signature: _____________________________________Date:______/______/______
Parent/Guardian Printed Name: ____________________________________
Parent/Guardian Signature: ______________________________ Date: ______/_____/______
*If the athlete is under the age of 18 years of age they must have a Parent/Guardian’s
signature.

Form H
Centenary College Sports Medicine
Informed Consent for Medical Treatment
Name: _______________________________
Date of Birth: _____/_____/_____
Sport(s):_____________________________
Centenary College employs Certified Athletic Trainers (ATC’s) who are qualified to
assess, treat, and rehabilitate injuries and illnesses you may incur while participating in
our intercollegiate athletic program. The Staff Athletic Trainer’s qualifications include:
national certification (ATC) by the Board of Certification, Licensed by the Louisiana
State Board of Medical Examiners, certification in First Aid/AED and Cardiopulmonary
Resuscitation for the Professional Rescuer, and a minimum of a Bachelor’s degree in the
Athletic Training field.
I hereby grant permission to the Centenary College team physician and athletic training
staffs to assess, treat, and rehabilitate any injuries that I may suffer as a result of my
participation in the Centenary College intercollegiate athletic program. I understand that
any treatment, medical or surgical care that is provided to me will be done only if it
considered medically necessary for my health.
I hereby grant my permission to the Centenary College team physicians, and athletic
training staff to refer me as they deem appropriate to the appropriate medical personnel,
to a hospital, or any other medical facility for treatment for any injury or illness that I
may suffer as a result of my participation in the Centenary College intercollegiate athletic
program.
I understand that it is my responsibility as a student-athlete, that should I suffer an injury,
suspect a concussion, or become ill, to report the injury/concussion/illness to a member
of Centenary College Athletic Training Staff as soon as possible. Costs pertaining to an
injury and/or illness not reported in a timely manner (48 hours) may be the
responsibility of the student-athlete and/or his/her parent/guardian(s).
Student-Athlete Name:______________________________
Student-Athlete Signature:___________________________ Date:_____/_____/______
Parent/Guardian Name:_____________________________
Parent/Guardian Signature:__________________________ Date_____/_____/_______