Dear 2015-2016 Incoming Student-Athletes of Macalester College,

On behalf of the Athletic Training Staff we would like to take this opportunity to welcome you to
Macalester College and the Athletics Department. We are looking forward to meeting you this fall as
you join your team and participate as a Macalester Student-Athlete. As you are preparing for your first
year at Macalester, we would like to give you a couple of things that we need you to do in order to be
eligible to participate in the athletics program at Macalester College.
1. Complete the following medical information packet:
A full health physical must be performed by your family physician.
This physical needs to be done within 6 months of your first practice with your team at
Macalester College.
Pages 9 and 10 of this form are what you take to your Doctor/Physician to complete!
2. Complete an online medical history:
This can be found at: www.swol123.net.
This can only be done after you have received your Macalester email address.
To begin, enter your email address and your password.
Your default password will be the first letter of your first name and your entire last name.
You can change this once you are logged in.
Click on the My Info tab and COMPLETE the general, address, emergency contact
and insurance tabs. Then click on Med History tab and complete the medical
history questionnaire.

Please mail the completed packet to us by July 15th for Fall sport athletes and August 1st for
all other teams, to: Matt Seamon, Assistant Athletic Trainer 1600 Grand Ave., St. Paul, MN 55105
As you are completing your paperwork, if you have any questions or concerns, please do not hesitate
to contact us at the email or phone numbers listed below.
If you have any questions specific to medical insurance, please contact Sue Rothenbacher,
Macalester College Insurance Coordinator, at rothenbacher@macalester.edu.
We hope you have a wonderful summer and we are looking forward to meeting you in the fall.
Sincerely,
Paula Natvig, A.T.,C.
Head Athletic Trainer
Macalester College
1600 Grand Ave.
St. Paul, MN 55105
natvig@macalester.edu
651-696-6162 office phone

Matt Seamon, A.T.,C

Assistant Athletic Trainer
Macalester College
1600 Grand Ave.
St. Paul, MN 55105
mseamon@macalester.edu
651-696-6404 office phone

1
STUDENT INTERCOLLEGIATE ATHLETES May 2015
Macalester Athletics
Macalester College 1600 Grand Avenue St. Paul, MN 55105
Athletic Training: 651-696-6404 Fax: 651-696-6839
Head Athletic Trainer: natvig@macalester.edu Assistant Trainer: mseamon@macalester.edu
_______________________________________________________________________________________________________________________________________

I. REQUIREMENTS FOR INTERCOLLEGIATE ATHLETES:

In addition to the Immunization Record, TB Screening/Testing, and Privacy Statement, you must complete & return
the health history, physical, and athletic insurance forms by

July 15, 2015.

Completion of these forms is required in order to participate in intercollegiate athletics. We strongly recommend that the
physical and approval be completed at home because it could cost approximately $250 or more to have the physical (must be within the
last six months) and necessary immunizations in the St. Paul community these services are offered by Macalester College, but fall
sport athletes participation may be delayed if it is completed here.
Paula Natvig, Head Athletic Trainer, coordinates athletic medicine for Macalester College

II. HEALTH INSURANCE : Macalester College requires ALL students show proof of comprehensive personal health

insurance coverage. Health insurance is NOT required to use the health & wellness services offered at the college but is needed for
any care or service off-campus and to participate in intercollegiate athletics.
a. Athletes are asked to provide an actual copy of their insurance card for the records of the athletic department . NOTE: This is
separate from enrolling in/waiving out of the college-offered health insurance policy you still need to go online and do that step (See
next paragraph).
b. All students are charged for the health insurance on the first bill every year. Macalester College requires that all students each
year either enroll or waive out of the insurance plan offered by the college. If you waive out, the charge is removed on the next bill.
If you enroll, the charge remains. If you do not do either one of these, you will automatically be enrolled in this plan and the charge
remains on your bill. See the website on Health Insurance http://www.macalester.edu/health/insurance.html .
The enroll/waive out process begins approximately July 1, 2015 and the deadline to complete the process is September 4, 2015.
If you have questions, please email them to health@macalester.edu . Note that the office is only staffed part-time during June and
July. We will get back to you as soon as possible.
Sue Rothenbacher, Executive Assistant, assists students and their families with the Macalester insurance plan and works directly with students
who have questions regarding insurance coverage, submitting for reimbursement, etc. Questions concerning the athletics-required insurance
information should be directed to Matt Seamon, Athletics.

III. ATHLETICS REQUIREMENTS CHECKLIST (To be completed and mailed to above address before July 15, 2014):
1.

Complete Information form and Medical History (pages 3-8)

2.

Take the medical history and pages 9-10 of this form to your physician and have your medical physical
completed. Be sure all portions are completed and signed. NCAA rules requires that this physical is
performed 6 months or less prior to your first team practice.

3.

Complete Insurance Requirement (page 11 and 12) and attach copies of insurance card

4.

Complete the HIPPA agreement (page 13) Sickle Cell trait form (page 14) and attach test results and Consent
for treatment form (page 15). Send entire packet to Matt Seamon at 1600 Grand Ave St. Paul, MN 55105

5.

Go to www.swol123.net to complete our online medical information. Please use your Macalester College email
address to sign in as your login and your password is the first letter or you first name and your entire last

name. Contact Matt @ mseamon@macalester.edu if you have problems with this! Complete the following
sections: General,

Address, Emergency, Insurance and under My Info fill out the medical
history questionnaire.

Macalester Athletic Training

Athlete Information Form 2015/2016
Athlete Information
Name of Athlete:___________________Sport(s): _________Year in School: fr so jr sr
Date of Birth: ___________________ Social Security #
(Required for insurance purposes)
Local Address
Student Athlete Cell Phone:
Parent/Guardian Information
Mother/Guardian Name: __________________________________________________
Day Phone: ________________________ Evening Phone: ______________________
Address: ______________________________________________________________
City/State/Zip: _________________________________________________________
Email: _________________________________
Father/Guardian Name: ___________________________________________________
Day Phone: ________________________ Evening Phone: _____________________
Address: _______________________________________________________________
City/State/Zip: __________________________________________________________
Email: _________________________________

Emergency Information (different from above ex. Grandparent, sibling or family friend)
Person(s) to be contacted in case of emergency: _______________________________
Relationship:
Day Phone:
Evening Phone:

MACALESTER COLLEGE
Athletics Department
1600 Grand Avenue, Saint Paul, Minnesota 55105
Athletics : Phone : 651.696. 6404 FAX : 651.696.6839
Return completed forms to: Matt Seamon Assistant Athletic Trainer,

Form must be
completed and
returned by mail, fax
or e-mail before

July 15

1600 Grand Ave., St. Paul, MN 55105

FAX : 651.696.6839
EMAIL : mseamon@macalester.edu

STUDENT-ATHLETE HEALTH HISTORY RECORD 2015-16

I. STUDENTS REPORT OF MEDICAL HISTORY (PLEASE PRINT)

==================================================================================

Last Name

First Name

Middle

Gender

Date of Birth

__________________________________________________________________________________________
Home Address (Number and Street)

City or Town

State

Country

Zip

_______________________________________________________________________________________________________________
Next of Kin: Name
Relationship
Primary Phone Number
Secondary Phone Number

_________________________________________________________________________________
Name of person to call in case of emergency :

Relationship

Primary Phone Number

Secondary Phone Number

_______________________________________________________________________________________________________________________________
Students Email Address
Students Cell Phone Number

___________________________________________________________________________________________________________________________________________
Primary Health Care Provider (print name)
___________________________________________________________________________________________________________________________________________
Primary Health Care Provider Office Phone Number

Family History

Current Age/Occupation

Health Status:

Fathers Name
Mothers Name
Siblings Names

Are you adopted?

Yes No

With whom do you live? Parents Mother Father Spouse Self Other

PLEASE CIRCLE YES and explain on PAGE 8; if you have had any of the following diseases
or conditions or CIRCLE NO if you have not had the following diseases or conditions

GENERAL
Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports?
Do you have ongoing medical conditions (i.e. diabetes, asthma)?

Yes

No

Yes

No

Have you ever spent the night in a hospital?

Yes

No

Have you ever had surgery?

Yes

No

Have you ever had a hernia?

Yes

No

Were you born without or are you missing a kidney, an eye, a testicle, or any other organ?

Yes

No

Have you ever been told you have protein/sugar in your urine?

Yes

No

When exercising in the heat, do you have severe muscle cramps or become ill?

Yes

No

Do you have any concerns that you would like to discuss with a doctor?

Yes

No

Do you have allergies to any medications?

Yes

No

If yes, please list

Other allergies:

Yes

No

Have you ever passed out or nearly passed out DURING exercise?
Have you ever passed out or nearly passed out AFTER exercise?

Yes

No

Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?

Yes

No

Does your heart race or skip beats during exercise?

Yes

No

Has a doctor ever told you that you have? (circle all that apply)
High Blood Pressure
High Cholesterol
A Heart Infection or Murmur
Rheumatic Fever
Has a doctor ever ordered a test for your heart? (i.e. ECG, echocardiogram, stress test)
Has anyone in your family died suddenly and unexpectedly for no apparent reason?

Yes

No

Yes

No

Does anyone in your family have a heart problem?

Yes

No

Has any family member or relative died of heart problems or of sudden death before age 50?

Yes

No

Does anyone in your family have Marfans syndrome?

Yes

No

ALLERGIES

If yes, please list

CARDIOVASCULAR

ORTHO
5

Have you ever had an injury, like a sprain, muscle or ligament tear or tendonitis that caused you
to miss a practice or a game?
Have you had any broken or fractured bones, or dislocated joints?

Yes

No

Yes

No

Have you had a bone/joint injury that required x-rays, MRI, CT, surgery, injections,
rehabilitation, physical therapy, a brace, a cast or crutches?
If yes, circle below:
Head Neck Shoulder Chest Upper Arm Elbow Forearm Hand/Fingers Upper Back
Lower Back Hip Thigh Knee Calf/Shin Ankle Foot/Toes
Have you ever had a stress fracture or stress reaction?
Have you been told that you have or have you had an x-ray for atlantoaxial (neck) instability?

Yes

No

Yes

No

Yes

No

Do you regularly use a brace or assistive device?

Yes

No

Have you ever had bronchitis?

Yes

No

Has a doctor every told you that you have asthma or allergies?

Yes

No

Do you cough, wheeze, chest tightness, or have difficulty breathing during or after exercise?

Yes

No

Is there anyone in your family who has asthma?

Yes

No

Have you ever used an inhaler or taken asthma medicine?

Yes

No

Do you develop a rash or hives when you exercise?

Yes

No

Do you get tired more quickly than your friends do during exercise?

Yes

No

Have you recently had a Tuberculosis Skin Test?

Yes

No

If you answered Yes above, the results were:

Yes

No

RESPIRATORY

INFECTIOUS

Have you had infectious mononucleosis (mono) within the last month?
Have you had chicken pox?

Negative
Positive
Yes
No

Have you had German measles?

Yes

No

Have you had measles?

Yes

No

Have you had mumps?

Yes

No

Do you have any rashes, pressure sores, or other skin problems?

Yes

No

Have you had a herpes skin infection?

Yes

No

Have you ever had a head injury; concussion; been knocked out or head your bell ring?

Yes

No

Have you been hit in the head and been confused or lost your memory?

Yes

No

SKIN

NEUROLOGIC

Have you ever had a seizure?

Yes

No

Do you have headaches with exercise?

Yes

No

Have you ever had a stinger or burner

Yes

No

Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or
falling?
Have you ever been unable to move your arms or legs after being hit or falling?

Yes

No

Yes

No

Have you ever been told you are anemic?

Yes

No

Has a doctor told you that you or someone in your family has sickle cell trait or sickle cell
disease?
Have you been tested for sickle cell trait?

Yes

No

Yes

No

BLOOD

If you answered Yes above, the results were:

Negative
Positive

What was the date of your sickle cell test?

____/____/____
Yes
No

Any other blood disorder?

VISION
Have you had any problems with your eyes or vision?

Yes

No

Do you wear glasses or contact lenses?

Yes

No

Do you wear protective eyewear, such as goggles or a face shield?

Yes

No

NUTRITION
Are you taking any vitamins or supplements?

Yes

No

Are you happy with your weight?

Yes

No

Are you trying to gain or lose weight?

Yes

No

What has been your highest & lowest weight in the past 12 months?

High
Low
Yes

No

Do you limit or carefully control what you eat?

Yes

No

Have you ever been diagnosed with an eating disorder?

Yes

No

Has anyone recommended you change your weight or eating habits?

FEMALES ONLY
Have you ever had a menstrual period?

Yes

No

How old were you when you had your first menstrual period?

Yes

No

How many menstrual periods have you had in the last year?

MALES ONLY
7

Have you ever had an injury to a testicle or other reproductive organs?

Yes

No

Do you or have you had undescended testicles?

Yes

No

Have you had multiple ear infections?

Yes

No

Do you have loss of hearing in one or both ears?

Yes

No

Have you had your tonsils or adenoids taken out?

Yes

No

Have you ever had an ulcer?

Yes

No

Do you have a history of gastrointestinal (GI) problems?

Yes

No

Do you experience abdominal pain multiple times per month?

Yes

No

Have you had your appendix removed?

Yes

No

ENT

ABDOMINAL

UROLOGY
Have you had multiple urinary tract /bladder infections?

Yes

No

Have you ever had a kidney infection?

Yes

No

Have you ever had kidney or gall stones?

Yes

No

PERSONAL HISTORY
PLEASE ELABORATE ON ANY POSITIVE ANSWERS WITH ADDITIONAL COMMENTS IN THE SPACE
PROVIDED BELOW. (ALL ANSWERS ARE CONFIDENTIAL)
IF YOU HAVE ANY DRS NOTES, PHYSICAL THERAPY NOTES, SURGERY NOTES, ETC OF A PAST INJURY,
PLEASE SEND THEM WITH THIS PACKET OR BRING THEM WITH YOU TO MACALESTER!

___________________________________________________________________________________________
A.
List any illness, injury, surgery, or hospitalizations (please give dates and explain).

_____________________________________________________________________________________________
B.
Do you take medication routinely? Reason and Type:
Yes No

_____________________________________________________________________________________________
C.
Do you have any food allergies or dietary restrictions?(i.e. vegetarian, lactose intolerant, gluten free, etc.)
Yes No

_____________________________________________________________________________________________
D.
Have you ever been diagnosed and/or treated for ADD/ADHD
Yes No
Do you currently take medication to help manage your ADD/ADHD? If yes, what do you take?

_____________________________________________________________________________________________
E.
Have you ever been diagnosed or treated for a mental health condition
Yes No
If yes, for which of the following conditions have you been diagnosed or treated? (Please check all that
apply)
Depression
Anxiety
Substance abuse or dependency

Bipolar Disorder
Anorexia or bulimia
Other (please list: _____________________________________

F.

Do you currently take medication to help manage a mental health condition?

Yes No
If yes, what do you take?__________________________________________________________

G.

Have you ever been hospitalized for a mental health condition?

Yes No
Macalester College
MEDICAL EXAMINATION
TO BE COMPLETED BY THE EXAMINING HEALTH CARE PROVIDER (i.e. MD, DO, NP, PA)
RETURN TO: Matt Seamon Assistant Athletic Trainer, 1600 Grand Ave., St. Paul, MN 55105

Students Name

Date of Birth

Age

Gender

MEDICAL EXAMINATION MUST BE COMPLETED WITHIN 6 MONTHS OF COMING TO MACALESTER

Height: _______________ Weight: ______________

BMI (optional) _______________ Arm Span ______________(optional screen for Marfan Syndrome)

Pulse: ________________

BP: _________/_________ Hearing Screen:

Vision: R - 20/________

L 20/ __________

Corrected: Yes/No

Right ________

Contacts Yes/No

Left _________ (Audiogram or confrontation)

Pupils: Equal __________ Unequal _________

LAB (if necessary) Results: ________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________

EXAM

NORMAL

ABNORMAL (explain)

Appearance
Y/N
HEENT
Y/N
Eyes
Y/N
Fundoscopic
Y/N
Pupils
Equal/Unequal
Ears/Nose
Y/N
Hearing
Y/N
Throat
Y/N
Dental
Y/N
Lymph Nodes
Y/N
Thyroid
Y/N
Lungs
Y/N
Abdomen
Y/N
Genitourinary (male)
Y/N
Hernia
Y/N
Skin
Y/N
Musculoskeletal
Neck
Y/N
Back
Y/N
Shoulder/Arm
Y/N
Elbow/Forearm
Y/N
Wrist/Hand/Fingers
Y/N
Hip/Thigh
Y/N
Knee
Y/N
Leg/Ankle
Y/N
Foot/Toes
Y/N
Duck Walk
Y/N
Neurological
Y/N
Psychological
Y/N
CARDIAC
Y/N
Is patient under treatment of any kind at this time? Yes :
No
Explain:
Physical/Mental Disabilities or impairment?
Explain:

Yes :

No

Please continue on to next page to complete, sign and date.

Macalester College
INTERCOLLEGIATE SPORT MEDICAL CLEARANCE FORM
RETURN TO: Matt Seamon Assistant Athletic Trainer, 1600 Grand Ave., St. Paul, MN 55105

Student Name: ______________________________________________________ Date of Birth: _____________ Gender: _________

Anticipated sport(s) participation (see list below):____________________________________________________________________

10

Date of Examination: _______________________

I certify that the above student has been medically evaluated and is deemed to be physically fit to:
(Check one box)
_____Participate in ALL Macalester Varsity or Club Sports
_____Not cleared for these specific sport activities (list all that apply) EXPLAIN: ____________________________________________
_________________________________________________________________________________________________________
_____Not cleared for ANY sports activities.
EXPLAIN: ______________________________________________________________
__________________________________________________________________________________________________________
_____Requires further evaluation before a final recommendation can be made. EXPLAIN: ____________________________________
__________________________________________________________________________________________________________

I have examined the above named student, reviewed their health history form and have completed the sports qualifying physical
examination as requested.
Health Care Provider Signature: _______________________________ Printed Name: ______________________________________
Clinic Address: _________________________________________________________________________________________________
Office Phone: __________________________Office Email: ______________________Office FAX: ____________________________

MACALESTER COLLEGE SPORT ACTIVITIES 2015-16

Intercollegiate Sports
Baseball
Golf
Tennis
Basketball
Soccer
Track & Field
Cross Country
Softball
Volleyball
Football
Swimming/Diving
Water Polo (women)

MACALESTER COLLEGE INTERCOLLEGIATE ATHLETICS

INSURANCE REQUIREMENTS
RETURN TO: Matt Seamon Assistant Athletic Trainer, 1600 Grand Ave., St. Paul, MN 55105 or mseamon@macalester.edu

Macalester College requires all students to demonstrate evidence of health insurance every year.
Students must go online to either opt out of the college Health Insurance policy by providing
information on coverage or waive in to purchase the policy that the College offers. In addition, all
Macalester College intercollegiate student-athletes must provide evidence of insurance that
includes coverage for athletically-related injuries and coverage of up to $90,000.00. This is a
NCAA requirement and a prerequisite for practice and competition. No student will be allowed to
participate in any way until such evidence of current insurance coverage is on file with the
Macalester College Department of Athletics. The below Acknowledgement of Insurance
11

Requirements form and photocopy of both sides, must be on file before a student can participate.
Insurance must provide coverage up to a minimum of $90,000 and cover athletically-related
injuries. Macalester College 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 Macalester College.
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
athletically-related injuries. Also, please be sure that your insurance will cover your student-athlete
in the Twin Cities Metro Area of Minnesota. We do highly recommend that student-athletes
consider enrolling in the student insurance policy offered by Macalester College through Aetna.
This policy will give very good coverage of injury and illness while your student-athlete is living
in St. Paul. For more information on this policy please visit this website:
http://www.macalester.edu/health/insurance.html
The team physicians that we
use at Macalester College are at Allina Health Sports and Orthopaedic
Specialists (8100 West 78th Street, Suite 225, Edina, MN). Please check with your insurance
company to find out if your student-athlete will be covered at this facility. For imaging services our
preferred provider is CDI (Center for Diagnostic Imaging). We are able to refer student-athletes to
other facilities if the need arises. Please advise us of the covered facilities in this area if the above
clinics are not covered by your insurance.
The NCAAs Catastrophic Injury Insurance Program covers student-athletes who are
catastrophically injured while participating in a covered intercollegiate athletic activity (subject to
all policy terms and conditions). The policy has a $90,000 deductible. This coverage does not
qualify as the basic coverage required for participation in athletics at Macalester College. It is
supplemental coverage in the event of a catastrophic injury. More information on this program
can be found on the NCAAs web-site at www.ncaa.org
If you have any questions regarding this requirement, please contact Matt Seamon at 651-696-6404
or mseamon@macalester.edu.

Acknowledgement of Insurance Requirements

STUDENT ATHLETE

I,

MACALESTER
COLLEGE ID

______________
__________
(Name, please print)

DATE OF BIRTH

SPORT

as parent, guardian, or legal representative attest

that____________________________
(Student-Athlete Name, please print)

has insurance coverage under a current

insurance policy for injuries that occur while he/she is participating in intercollegiate athletics.
12

This policy covers claims to at least $90,000.

If there is a material change in coverage or expiration of coverage, I agree to notify
Macalester College of this development and update the insurance information I have on file
with Macalester College.
I understand and agree that Macalester College 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 Macalester College.
______________________
(Parent Signature)

_____________
(Date)

PLEASE ATTACH COPIES OF YOUR INSURANCE CARD(S) BELOW

FRONT of Insurance Card
(please secure all edges with glue or tape)

BACK of Insurance Card

(please secure all edges with glue or tape)

Student-Athlete Authorization/Consent for

Disclosure of Protected Health Information
I, ____________________________ hereby authorize Macalester College and its physicians, athletic trainers
Name of Student-Athlete
and health care personnel to disclose my protected health information including, without limitation, any information
regarding any injury, illness, treatment or participation related to or affecting my training for and participation in
intercollegiate athletics to the National Collegiate Athletic Association (NCAA), and its designated employees, agents
and/or contractors. I further authorize the NCAA to disclose, and/or use, such information as provided herein.
I understand that my participation and protected health information, including, without limitation, injuries or illnesses
resulting from or affecting training for or participation in athletics, may be disclosed to, and/or used by, the NCAA, and

13

any third party expressly authorized by the NCAA to receive such information for the purposes described in this
paragraph. The information provides NCAA committees, athletics conferences and individual schools and NCAAapproved researchers with injury, relevant illness and participation information that does not identify individual studentathletes or schools. The data provide the Association and other groups with an information resource upon which to base
and evaluate the effectiveness of health and safety rules and policy, and to study other sports medicine questions.
Selected de-identified summary (aggregate) data also are made accessible to the general public as a service to further the
general understanding of athletic injury patterns.
I understand that my protected health information is protected by federal regulations under either the Health Information
Portability and Accountability Act (HIPAA) or the Family Educational Rights and Privacy Act of 1974 (the Buckley
Amendment) and may not be disclosed without either my authorization under HIPAA or my consent under the Buckley
Amendment. I understand that my signing of this authorization/consent is voluntary and that my institution will not
condition or withhold any health care treatment or payment, enrollment in a health plan or receipt of any benefits (if
applicable) on whether I provide the consent or authorization requested for this disclosure. I also understand that I am
not required to sign this authorization/consent in order to be eligible for participation in NCAA athletics.
I understand that while HIPAA regulations may not apply to NCAA use or disclosure of my injury/illness information,
the NCAA is committed to protecting my privacy. I understand that my protected health information and any personal
identifiers will be encrypted while being transmitted from my institution and, to the extent kept by the NCAA, that all
such data will be stored securely within industry standards. I further understand that neither the NCAA nor its agents or
contractors will identify me personally in any publication or disclosure of research results.
This authorization/consent for transfer of protected health information expires 545 days from the date of my signature
below but I have the right to revoke it in writing at any time by sending written notification to the director of athletics at
my institution. I understand that a revocation takes effect on its request date and does not affect any action taken prior to
that date.
_____________________________________
Printed Name of Student-Athlete
Signature

Date

Macalester College Sickle Cell Trait Form for NCAA Intercollegiate Athletics
About Sickle Cell Trait

Sickle cell trait is not a disease. Sickle cell trait is an inherited condition affecting the oxygen-carrying substance,
hemoglobin, in the red blood cells. You are born with sickle cell trait; it cannot be developed over time or contracted like
a disease.
Sickle cell trait is a common condition (> three million Americans)
Although Sickle cell trait occurs most commonly in African-Americans and those of Mediterranean, Middle Eastern,
Indian, Caribbean, and South and Central American ancestry, persons of all races and ethnicities may test positive for this
condition.
Those with sickle cell trait usually have no symptoms or any significant health problems. However, sometimes during
very intense, sustained physical activity, as can occur with collegiate sports, certain dangerous conditions can develop in
those with sickle cell trait, leading to blood vessel and organ (kidneys, muscles, heart) damage that can cause sudden
collapse and death. Some of the settings in which this can occur include timed runs, all out exertion of any type for 2 to 3
continuous minutes without a rest period, intense drills and other bursts of exercise after doing prolonged conditioning

14

training. Extreme heat and dehydration increase the risks. (NCAA: A Fact Sheet for Coaches, Sickle Cell Trait,
http://web1.ncaa.org/web_files/health_safety/SickleCellTraitforCoaches.pdf)
More information and resources regarding sickle cell trait and the NCAAs recommendation for sickle cell trait testing can
be found at the NCAA web site resource pages regarding the sickle cell trait, accessible at: www.NCAA.org/health safety.

Sickle Cell Trait Testing

The NCAA recommends that all student-athletes have knowledge of their sickle cell trait status. Student-athletes must 1)
show proof of a prior test with results; 2) have a blood test to check for sickle cell trait; or 3) sign a testing waiver
declining options 1 and 2. Whichever option is chosen, it must be completed before the athlete participates in any
intercollegiate athletics event, including strength and conditioning sessions, practices, competitions, etc.
Macalester College recommends that all student-athletes who are unable to confirm their sickle cell trait status undergo
sickle cell trait testing prior to participation in any intercollegiate athlete activity.
Athletes who are positive for the trait will be allowed to participate in intercollegiate athletics; this does NOT prohibit you
from playing.

One of the following options must be chosen. Include any documentation if necessary:
Copy of athletes newborn sickle cell testing result attached. ________
Date: ____________
Most states require testing at birth, check with your hospital or pediatrician
Copy of recent sickle cell screening test result attached. ________
Date: ____________
Cost of testing is the responsibility of the athlete
SICKLE CELL TESTING WAIVER:
By signing this waiver I understand and acknowledge that the NCAA recommends that all student-athletes
have knowledge of their sickle cell trait status. Additionally, I certify that I have read and fully understand the
aforementioned facts and I have had the opportunity to review the NCAA website for further information about
sickle cell trait and sickle cell trait testing.
Recognizing that my true physical condition is dependent upon an accurate medical history and a full
disclosure of any symptoms, complaints, prior injuries, ailments, and/or disabilities experienced, I hereby affirm
that I have fully disclosed in writing any prior medical history and/or knowledge of sickle cell trait status to the
Macalester College Athletic Department.
I do not wish to undergo sickle cell trait testing and I voluntarily agree to release, discharge, indemnify and
hold harmless Macalester College, its officers, employees, agents and their successors and assigns from any and all
costs, claims, damages or expenses, including attorneys fees, arising from any loss or personal injury that might
result from my refusal to be tested.
I have read and signed this document with full knowledge of its significance. I further state that I am at least
18 years of age and competent to sign this waiver.
____________________________
___________________________
_______
Student-Athletes Signature
Student-Athletes Print Name
Date
______________________________
___________________________
Parent/Guardians Signature (if under 18 years of age)
Parent/Guardians Print Name

___________________
SPORT(s):
______
Date

CONSENT FOR TREATMENT AND AUTHORIZATION TO RELEASE

PROTECTED HEALTH INFORMATION
First Name

Last Name

Date of Birth

Age

Sport(s)
I understand that Macalester College employs Certified and Registered Athletic Trainers for
the purposes of preventing, treating and educating student-athletes about injuries and
illness that may be incurred while participating in school-related athletic events and
programs. As a student-athlete, I understand that I have to be an active participant in my
own healthcare by reporting all of my injuries and illnesses to the Athletic Training Staff. I
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hereby affirm that I have fully disclosed in writing any prior medical conditions and will also
disclose any future conditions to the Macalester College Athletic Training Staff.
I further understand that there is a possibility that participation in my sport may result in a
head injury and/or concussion.
By signing below, I acknowledge that my institution has provided me with specific
educational
materials on what a concussion is, about the importance of immediately reporting
symptoms and given me an opportunity to ask questions about areas and issues that are
not clear to me on this issue. I also acknowledge that I have received and understand the
educational information on Sickle Cell Trait and testing
In accordance with HIPAA guidelines, I give the following approvals for injuries resulting
from participation at Macalester College in intercollegiate athletics. By my signature, I agree
that the Macalester College Athletic Training staff can function with my approval of releases
of injury or illness information. I also give my consent for treatment of my injuries by the
Athletic Training staff
This approval will last for one calendar year. I understand this authorization form must be
filled out completely and signed in order to be considered valid.
A copy that has not been altered will be considered as valid as an original. I can at any time
revoke this approval, to do so; it must be in a written form to the Macalester College Athletic
Training staff.
I approve that the Macalester Athletic Training Staff can/may:
Give injury/illness information from above sport(s) to the head and assistant coaches of the sport(s) I am
involved in.
Discuss my medical history with Macalester College team physicians, Macalester College Health and
Wellness Center and other qualified medical providers when pertinent to my athletic participation.
Email, mail, or fax information regarding my injuries/illness that are related to intercollegiate athletics to
team physicians, referring physicians, Health and Wellness Center and/or my insurance company.
Contact with the Office of Student Affairs staff for academic services, disability services, and other services as deemed
needed.
I understand that the Macalester College Athletic Trainers adhere to the Notice of Privacy Practices & this
information can be viewed at www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/notice.html

I have read and understand the contents of this form

Signature:
Parents Signature (if under the age of 18)

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Date:
Date: