UNIVERSITY OF UTAH ATHLETICS

Transcription

1 Athletics Compliance Office STUDENT-ATHLETE MEDICAL RELEASES UNIVERSITY OF UTAH ATHLETICS Student-Athlete Name Sport ID # Student-Athlete Local Address Student-Athlete Phone # of Birth PART I: Assumption of Risk, Release of Liability and Consent to Medical Treatment As a condition of my participation in the University of Utah Athletics Department tryouts ( Tryouts ), and in consideration for the privileges that come from participation in the Tryouts which may include use of University facilities and equipment, I hereby agree as follows: 1. I recognize and understand that there are certain risks of harm to me and others associated with my participation in the Tryouts, that there are dangers that cannot be fully foreseen, that there are risks and dangers that the University of Utah, the Athletics Department, and their agents and employees (hereinafter collectively the University ) cannot control, and that such risks and dangers could result in bodily injury or death to me and/or to others. 2. I understand that some of the dangers and inherent risks to me in participation in the Tryouts include, but are not limited to, death, serious neck and spinal injuries which may result in complete or partial paralysis, brain damage, serious injury related to the eye and/or head, serious injury to virtually all internal organs, serious injury to all bones, joints, ligaments, muscles, tendons, and other parts of the muscular/skeletal system, and serious injury or impairment to other aspects of my body and general health and well-being. 3. By signing this form, I am representing to the University that I am physically healthy and that I do not have any medical conditions that would/should prevent me from participating in the Tryouts. I acknowledge that the University has strongly recommended to me that I seek medical advice concerning my physical health, conditioning and abilities, prior to engaging in the Tryouts. 4. If I incur any injury or emergency during the Tryouts, I authorize the University to take whatever steps are reasonably necessary in its judgment to attend to my medical needs. I also authorize the University athletics team physicians and athletics trainers to administer treatments deemed necessary. 5. Except as otherwise covered by health insurance policies, I agree to assume all risks and responsibility for any and all claims for damages, including personal injury or death, medical expenses, disability, lost wages, loss of earning capacity and property damages which may be incurred by me while I engage in, and as a result of, the Tryouts. 6. I agree to assume all risks and responsibility for any and all claims for damages, including personal injury or death, medical expenses, disability, lost wages, loss of earning capacity and property damages which may be made by others and that result in part from my participation in the Tryouts. 7. I agree to indemnify and hold harmless the University from any loss liability, damage or costs, including court costs and attorney fees that they may incur due to my participation in the Tryouts, whether caused by my negligence, the negligence of others and/or by the negligence of the University (excluding the sole negligence of the University). APPROVAL In signing this release, I acknowledge and represent that I have carefully read the foregoing, that I understand it, and that I sign it voluntarily as my own free act and deed. No one has made any oral representation, statements, or inducements in order to get me to sign this document. I have had the opportunity to consult with my own legal counsel before signing this document. I am at least eighteen (18) years of age and fully competent. I execute this Release in order to receive the benefits provided by the Athletics Program and fully intend to be bound by this document Finally, if I have not provided sickle-cell solubility test results to an athletic trainer I decline the test and waive all liability related to it.. Student-Athlete (Print) UID Local Address of Birth Student-Athlete Signature Phone PART II: Emergency Contact Information Name of Emergency Contact Relationship Emergency Contact Phone Number Emergency Contact Address Distribution: Original- Athletics Compliance Office

2 Athletics Compliance Office STUDENT TRYOUT FORM UNIVERSITY OF UTAH ATHLETICS HEAD COACH & ATHLETIC TRAINER: This form is to be submitted to the Athletics Compliance Office after a student-athlete has expressed an interest in trying out for a sports team. Coaches, please remember a student must present a medical physical and sign the attached NCAA Drug Testing form and University Medical Liability form before participating in any athletic activity. Name (First, Middle Initial, Last) Sport UID # Student Are you enrolled in at least 12 credit hours at the University of Utah? Yes No Have you ever attended another college? Yes No 2-year college 4-year college Have you served an official religious mission? Yes No Mission dates Have you registered with the NCAA Eligibility Center? Are you considered a qualifier by the NCAA Eligibility Center? Have you had a physical examination conducted by a medical physician, dated within the last six months? Have you had a sickle-cell solubility test, dated within the last six months? If you have not had a sickle-cell solubility test, dated within the last six months, do you decline the test and waive all liability related to this test? Yes No Student Signature Athletic Trainer (Please return to Compliance Office) A valid medical physical, dated within the six months, is on file in the Athletics Training Room: Yes No A valid sickle-cell solubility test, dated within the six months, is on file in the Athletics Training Room: Yes No Signature of Athletic Trainer Distribution: Original- Athletics Compliance Office Copies- Athletic Training, Head Coach

3 Form 11-3d Drug-Testing Consent NCAA Division I For: Student-athletes. Action: Sign and return to your director of athletics. Due date: At the time your intercollegiate squad first reports for practice or the Monday of the institution's fourth week of classes, whichever date occurs first. Required by: NCAA Constitution and NCAA Bylaw Purpose: To assist in certifying eligibility. Effective date: This consent form shall be in effect from the date this document is signed and shall remain in effect until a subsequent Drug-Testing Consent Form is executed. Requirement to Sign Drug-Testing Consent Form. Name of your institution: You must sign this form to participate (i.e., practice or compete) in intercollegiate athletics per NCAA Constitution and NCAA Bylaw If you have any questions, you should discuss them with your director of athletics. Consent to Testing. You agree to allow the NCAA to test you in relation to any participation by you in any NCAA championship or in any postseason football game certified by the NCAA for the banned drugs listed in Bylaw (attached). Additionally, if you participate in a NCAA Division I sport, you also agree to be tested on a year-round basis. Consequences for a Positive Drug Test. By signing this form, you affirm that you are aware of the NCAA drug-testing program, which provides: 1. A student-athlete who tests positive shall be withheld from competition in all sports for a minimum of 365 days from the drug-test collection date and shall lose a year of eligibility; 2. A student-athlete who tests positive has an opportunity to appeal the positive drug test; 3. A student-athlete who tests positive a second time for the use of any drug other than a "street drug" shall lose all remaining regular-season and postseason eligibility in all sports. A combination of two positive tests involving street drugs (marijuana, THC or heroin), in whatever order, will result in the loss of an additional year of eligibility; 4. The penalty for missing a scheduled drug test is the same as the penalty for testing positive for the use of a banned drug other than a street drug; and 5. If a student-athlete immediately transfers to a non-ncaa institution while ineligible because of a positive NCAA drug test, and competes in collegiate competition within the 365-day period at a non-ncaa institution, the student-athlete will be ineligible for all NCAA regular-season and postseason competition until the student-athlete does not compete in collegiate competition for a 365-day period.

4 Drug-Testing Consent NCAA Division I Form 11-3d Page No. 2 Signatures. By signing below, I consent: 1. To be tested by the NCAA in accordance with NCAA drug-testing policy, which provides among other things that: a. I will be notified of selection to be tested; b. I must appear for NCAA testing or be sanctioned for a positive drug test; and c. My urine sample collection will be observed by a person of my same gender. 2. To accept the consequences of a positive drug test; 3. To allow my drug-test sample to be used by the NCAA drug-testing laboratories for research purposes to improve drug-testing detection; and 4. To allow disclosure of my drug-testing results only for purposes related to eligibility for participation in NCAA competition. I understand that if I sign this statement falsely or erroneously, I violate NCAA legislation on ethical conduct and will jeopardize my eligibility. Signature of student-athlete Signature of parent (if student-athlete is a minor) Name (please print) of birth Age Home address (street, city, state and zip code) Sport(s) What to do with this form: Sign and return it to your director of athletics at the time your intercollegiate squad first reports for practice or the Monday of the institution's fourth week of classes (whichever date occurs first). This form is to be kept on file at the institution for six years.

5 ATTACHMENT NCAA Banned Drugs 1. The NCAA Bans The Following Classes of Drugs. a. Stimulants; b. Anabolic Agents; c. Alcohol and Beta Blockers (banned for rifle only); d. Diuretics and Other Masking Agents; e. Street Drugs; f. Peptide Hormones and Analogues; g. Anti-estrogens; and h. Beta-2 Agonists. Note: Any substance chemically related to these classes is also banned. The institution and the student-athlete shall be held accountable for all drugs within the banned drug class regardless of whether they have been specifically identified. 2. Drugs and Procedures Subject to Restrictions. a. Blood Doping; b. Local Anesthetics (under some conditions); c. Manipulation of Urine Samples; d. Beta-2 Agonists permitted only by prescription and inhalation; e. Caffeine if concentrations in urine exceed 15 micrograms/ml. 3. NCAA Nutritional/Dietary Supplements Warning. Before consuming any nutritional/dietary supplement product, review the product with your athletics department staff! (1) Dietary supplements are not well regulated and may cause a positive drug-test result. (2) Student-athletes have tested positive and lost their eligibility using dietary supplements. (3) Many dietary supplements are contaminated with banned drugs not listed on the label. (4) Any product containing a dietary supplement ingredient is taken at your own risk. It is your responsibility to check with the appropriate athletics staff before using any substance.

6 NCAA Banned Drugs Page No. 2 Some Examples of NCAA Banned Substances in Each Drug Class NOTE: There is no complete list of banned substances. Do NOT rely on this list to rule out any supplement ingredient. Check with your athletics department staff before using any medication or supplement. 1. Stimulants. e.g., amphetamine (Adderall); caffeine (guarana); cocaine; ephedrine; fenfluramine (Fen); methamphetamine; methylphenidate (Ritalin); phentermine (Phen); synephrine (bitter orange); methylhexaneamine, etc. Exceptions: phenylephrine and pseudoephedrine are not banned. 2. Anabolic Agents (sometimes listed as a chemical formula, such as 3,6,17-androstenetrione). e.g., boldenone; clenbuterol; DHEA (7-Keto); nandrolone; stanozolol; testosterone; methasterone; androstenedione; norandrostenedione; methandienone; etiocholanolone; trenbolone; etc. 3. Alcohol and Beta Blockers (banned for rifle only). e.g., alcohol; atenolol; metoprolol; nadolol; pindolol; propranolol; timolol; etc. 4. Diuretics and Other Masking Agents (water pills). e.g., bumetanide; chlorothiazide; furosemide; hydrochlorothiazide; probenecid; spironolactone (canrenone); triameterene; trichlormethiazide; etc. 5. Street Drugs. e.g., heroin; marijuana; tetrahydrocannabinol (THC); and synthetic cannabinoids (e.g., Spice, K2, JWH-018, JWH-073). 6. Peptide Hormones and Analogues. e.g., growth hormone (hgh); human chorionic gonadotropin (hcg); erythropoietin (EPO); etc. 7. Anti-Estrogens. e.g., anastrozole; tamoxifen; formestane; 3,17-dioxo-etiochol-1,4,6-triene (ATD); etc. 8. Beta-2 Agonists: e.g., bambuterol; formoterol; salbutamol; salmeterol; etc. Any substance that is chemically related to the class, even if it is not listed as an example, is also banned (unless otherwise noted)! Information about ingredients in medications and nutritional/dietary supplements can be obtained by contacting the Resource Exchange Center, REC, 877/ or password ncaa1, ncaa2 or ncaa3. It is your responsibility to check with the appropriate athletics staff before using any substance.