department of athletics policies & procedures - UNC Wilmington ...

Acknowledgement of Responsibility and Risks Statement:
I am choosing to participate in intercollegiate athletics. I take personal responsibility for this decision.
I understand that participation in sport activity involves the potential for injury, which is inherent in all sports. I
acknowledge that even with the best coaching, guidance of athletic trainers, use of protective equipment, and
observance of rules, injuries are still a possibility. On rare occasions, these injuries can be so severe as to result in
total disability, paralysis or even death.
I understand that I must refrain from practice or play while ill or injured, whether or not receiving medical
treatment. I will make every effort to follow the directions of the athletic training staff and physicians providing
treatment to me for any injuries or illnesses. I understand that I may not resume competition or cease necessary
treatment for my injuries or illnesses until I am released to do so by a UNCW Team Physician and/or Athletic
Trainer.
I understand that this screening examination is not an all-encompassing process to detect and treat my overall
health. Rather, the screening questions/exam attempt to identify conditions which need further evaluation and
consideration before I can safely participate in intercollegiate sports. However, this screening process is not able to
detect all conditions which might put me at risk of injury or sudden death.
I certify that my answers on the Screening Examination Form are correct and accurate to the best of my
knowledge.
Student -Athlete Signature
Date
Parent/Guardian Signature (if under 18 yrs. of age)
Date
Consent for Treatment:
Permission is granted to the medical personnel (Athletic Trainers, Team Physician, and Student Health Center Staff)
at the University of North Carolina Wilmington to seek and/or initiate treatment for emergency medical care,
hospitalization, or any other medical treatment as may be necessary for the wellbeing of _________
____________________________.
(print student-athlete name)
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