Trinity Washington University Sports Medicine
Waiver, Release, and Consent to Treat
Assumption of Risk and Release:
I acknowledge that my participation in athletics at Trinity Washington University is voluntary and understand that
there are risks associated with my participation. I understand that the risks include, but are not limited to, personal
injury, disability, or even death. I voluntarily assume all the risks involved in participating in the athletic program at
Trinity, and I, on behalf of myself, and on behalf of those acting on my behalf, irrevocably and unconditionally
release and hold harmless Trinity Washington University and its officers, agents, and employees from any and
lawsuits, claims, and actions arising from or connected with my participation in the athletic program, including
practice sessions, games, events, and activities, and travel to and from such sessions, games, events, and activities
except to the extent such claims are solely caused by the gross negligence or intentionally willful actions of Trinity
Washington University.
Consent for Treatment and Release of Medical Information:
I give permission to members of the Trinity Washington University sports medicine department, associated
physicians, and designees to administer medical treatment to me, including emergency care, such as CPR. I
understand that it is my responsibility to inform the sports medicine staff of any injury, illness, change in pain,
medication, or abnormal responses to treatment and/or rehabilitation and that it is my responsibility to be present for
all treatment and rehabilitation sessions in order to best treat an associated condition. I also consent to the release of
information about any medical condition for use in connection with diagnosis, treatment, and/or rehabilitation of
such injuries or illness and for determinations of fitness to return o play. This authorization shall expire at the end of
the current academic year and/or the end of the competitive season, whichever occurs later in time.
Sickle Cell Status:
The NCAA recommends that all student-athletes be aware of their sickle cell status. If the student-athlete does not
know their sickle cell status, the NCAA recommends that s/he have a sickle cell solubility test administered before
participation. Trinity is supportive of the NCAA’s recommendation and requests that each student provide
documented results of a sickle cell solubility test before participation. If a student opts not to provide the university
with this information, s/he must sign a waiver. To help you make an informed decision regarding this issue, some
basic information is provided in the “Sickle Cell Trait Information Sheet / Waiver.”
Health Insurance Information/Waiver:
The Trinity Washington University Department of Athletics’ accident policy provides insurance for student-athletes
with injuries occurring only when participating in the play or practice of intercollegiate athletics. This
accident policy is considered “EXCESS” or “SECONDARY” to any other collectible group insurance benefits.
Therefore, any claims for benefits must first be filled with the group insurance company providing coverage. Only
after all available benefits have been exhausted will the Trinity Washington University Department of Athletics’
insurance carrier consider payment for any remaining balances. This policy is an “add-on” policy to the university’s
policy. The university’s policy will pay up to $2500 then the athletic policy will take effect. I hereby authorize the
Trinity Washington University Athletic Department, and associated physicians and hospitals, to furnish information
to insurance carriers concerning any illness, injury, and treatments, and I hereby assign the party to the party all
payments for medical services to the student-athlete. I agree to supply any and all information requested by
associated insurance companies in a timely manner. I hereby authorize the Trinity University Department of
Intercollegiate Athletics 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. A photocopy of this authorization shall be
deemed as effective & valid as the original. I agree to notify the Trinity University Sports Medicine Unit
immediately upon any change in the above health insurance information. If I fail to do so, I fully understand that I
may be responsible for any & all charges incurred. I hereby certify that I have read and understand the above
statements, that any and all questions have been answered to my satisfaction, and that the answers provided are true,
complete, & correct to the best of my knowledge.
By signing below, I confirm that I have read and understand the above information and agree to adhere to these
policies.
Student-Athlete’s Signature: ____________________________________________
Student-Athlete’s Name (Please Print):
_________________________________________________
Parent/Guardian Signature (if minor): ____________________________________
Parent/Guardian’s Name (Please Print):
Date: __________
Date: __________
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