BASKETBALL PROSPECTIVE STUDENT-ATHLETE TRYOUT CONSENT AND ELIGIBILITY FORMON-CAMPUS EVALUATION (OCE)
I.
PROSPECT INFORMATION
PROSPECT NAME:
ELIG. CENTER ID#:
________
HOME ADDRESS:
PHONE NUMBER: (
)
NAME OF HIGH SCHOOL/JC:
DATE OF VISIT: _____________
II.
BIRTHDATE:
_____
________________
EMERGENCY CONTACT INFORMATION
NAME:
RELATIONSHIP TO PROSPECTIVE STUDENT-ATHLETE___________
HOME ADDRESS:
HOME NUMBER: (
III.
)
CELL NUMBER: (
)
___
WORK NUMBER: (
)
ELIGIBILITY
By signing below, I certify that I am eligible to participate in a tryout with Stetson University Department of Athletics in the Sport of
Basketball. I also understand that prior to being approved to tryout; I must submit documentation of a physical examination that was
completed no more than six months prior to the date of my tryout.
□
□
□
I am currently (check one):
A high school senior who has exhausted my eligibility in Basketball.
A two-year college student who has exhausted my eligibility in Basketball.
A four-year college student who has received permission from my current school to contact Stetson University
___________________________________
PROSPECTIVE STUDENT-ATHLETE SIGNAUTURE
__________________________________
DATE
IV. CONSENT TO TREAT
I give authorization to the SU (Stetson University) Sports Medicine Staff to evaluate and treat injuries that occur during my tryout
participation at Stetson University. This consent includes, but is not limited to administration of immediate first aid and treatment, x-rays,
physical exam, follow-up and rehabilitation on the day of the tryout in the athletic training facility. I give authorization for my medical
records to be released from SU Sports Medicine Staff to my medical care providers and from my medical care providers to the SU Sports
Medicine Staff. I understand that the SU Sports Medicine Staff has the authority to prohibit me from further participation because of
injury, disqualifying medical condition, and/or because of an undue risk or liability exposure to Stetson University.
___________________________________
PROSPECTIVE STUDENT-ATHLETE SIGNAUTURE
__________________________________
DATE
Parent signature if prospect is under 18 on date of OCE
_________________________________________
Parent Signature
_______________________________________
DATE
ASSUMPTION OF RISK AND LIABILITY WAIVER
Prospective Student-Athlete’s Name :________________________
Sport:___________________
Stetson University offers prospective student-athletes the opportunity to participate in an on- campus
evaluation (OCE) or tryout. Certain potential risks to personal health and safety are inherently associated with
athletics and participation in sports tryouts requires an acceptance of the risks of injury. Those unwilling to
accept these associated risks should not participate in an OCE.
I wish to participate in the Stetson University intercollegiate athletic program OCE. Accordingly, I
ACKNOWLEDGE THAT I UNDERSTAND AND AGREE TO THE FOLLOWING:

It is my responsibility to know my state of health and I certify that I am physically able to participate in
the above-referenced OCE.

As a participant in an OCE I will be engaging in activities that involve risks of injury and loss, both to
person and property. The risks of injury include but are not limited to bruises lacerations, sprains,
strains, heat stroke, cardiac arrest, respiratory arrest, broken bones, and possibility of head, injury,
permanent disability and death. The causes of these risks may include, but are not limited to: (a) the
actions, omissions or negligence of Stetson University, its regents, officers, employees, or agents; (b)
travel to and from the site of the activity; (c) use and/or condition of the premises or equipment being
used; (d) rules of play; (e) temperature; (f) weather; and (g) conditions of participants or competitors. I
understand that this Assumption of Risk and Release is intended to address all risks associated with
my participation in intercollegiate athletics.

Particular rules, equipment, and personal discipline may reduce the risk of injury or property loss.
Nevertheless, the risk of injury, including permanent disability and death, property loss and severe
social and economical losses, still exists. I understand that Stetson University is not in a position to
guarantee my personal health or safety during my participation in an OCE.
I HAVE READ AND UNDERSTOOD THE ABOVE RISKS AND I VOLUNTARILY CHOOSE TO
PARTICIPATE IN A STETSON UNIVERSITY INTERCOLLEGIATE OCE. I KNOWLINGLY AND
FREELY ASSUME ALL RISKS AND RESPONSIBILITIES, KNOWN OR UNKNOWN, FORSEEABLE
AND UNFORSEEABLE, IN ANY WAY CONNECTED WITH MY.

In consideration of being permitted to participate in an OCE at Stetson University, I voluntarily
assume full responsibility for any loss, property damage, or personal injury, including death
that I may sustain as a result of participation. I, my heirs, personal representatives and assigns,
do hereby agree not to sue Stetson University and hereby release, waive, discharge, and hold
harmless Stetson University, its Board of Trustees, officers, employees, and agents from any
loss, property damage, illness, injury and death to myself, and any person, arising from my
participation or growing out of or caused during my participation in the OCE.

I have read this Assumption of Risk and Release and understand that I am giving up substantial rights,
including my right to sue. I intend that this Assumption of Risk and shall be construed broadly to
provide a release and waiver to the maximum extent permissible under applicable law.

This instrument shall be governed by the laws of the State of Florida.

If any portion of this Assumption of Risk is held invalid, the remainder will continue in full legal force and
effect.

I am signing this Assumption of Risk, Release and Liability Waiver freely and voluntarily.
Prospective Student-Athlete Signature
Date
Parent/Legal Guardian Signature
Date
(If prospective student-athlete is under 18 years of age)
Witness Signature
Date
Sickle Cell Trait Screening Form
Sickle Cell Trait (SCT) is a genetic (inherited) medical condition that has been associated with life threatening
health conditions in athletes who participate in intensive physical exercise. Although most infants in the United
States are checked for SCT, few adults are aware of these prior results.
The NCAA now requires that all student-athletes who do not know their Sickle Cell Trait status, be tested for
Sickle Cell Trait. Testing involves a blood test. This test can be arranged at the Wilson Athletic Center Athletic
Training Room. Please be advised that it takes a minimum of one full business day to receive the results of
this blood test.
Alternatively, if you choose not to be tested for SCT you must either:
1) Provide laboratory evidence of your SCT status; or
2) Decline to be tested, and sign the waiver below.
You may not participate in an On-Campus Evaluation until 1) your SCT results are received; 2) you provide
results of previous testing; or 3) you decline to be tested and sign this consent.
If you have any questions or concerns, please contact the SU Team Physicians or Athletic Trainers.
Completion of this form is a required component of your participation in an On-Campus Evaluation. Any
prospective student-athletes who receive a positive test result will be required to meet with a SU Team
Physician.
Please choose one option below, sign, and date:
( )
I DO choose to be tested for sickle cell trait.
( )
I have already been tested, know my results, and will provide written proof of my sickle cell trait
status.
( )
I DECLINE to be tested for sickle cell trait at this time, and release the Stetson University from
all liability relating to my sickle cell status.
_________________________
__________________________
Prospective Student-Athlete Printed Name
Parent/Legal Guardian Printed Name
(If prospective student-athlete is under 18 years of age)
______________________________
Prospective Student-Athlete Signature
________________________________
Parent/Legal Guardian Signature
(If prospective student-athlete is under 18 years of age)
______________________________
Date
_________________________________
Date
Prospective Student-Athlete ACCIDENT INSURANCE for On-Campus Evaluations
Dear On-Campus Evaluation Participant,
Welcome to Stetson University. In order to prepare ourselves for the upcoming tryout, we need to have current
and updated information before potential student-athletes can begin an On-Campus Evaluation (OCE).
All prospective student-athletes must report any athletically related illness or injury to their team’s Athletic
Trainer or the Team Physician before the Athletics Department can assist with any associated medical
expenses.
The Athletics Department provides secondary insurance for our prospective student-athletes for injuries
occurring while participating in the OCE. The policy is “excess” or “secondary” to any personal or parents' or
marital insurance benefits. This means that the prospective student-athlete’s own insurance or that of
the prospective student-athlete’s parents and/or spouse must be billed first. After the applicable
insurance plan has paid all available benefits, our athletic department insurance policy may pay any remaining
amount, to the maximum limit of our policy.
The Health Insurance Information Sheet is required for all OCE’s. This form supplies us with necessary
information to bill a prospective student-athlete's insurance for any bills incurred for treatment of an athletic
injury. No medical expenses will be paid out of athletics department funds without a signed, accurate
information sheet on file. It is the prospective student-athlete’s sole responsibility that the provided information
is current.
Please complete and return the Health Insurance Information Sheet with the rest of the BASKETBALL
PROSPECTIVE STUDENT-ATHLETE TRYOUT CONSENT AND ELIGIBILITY FORM- OCE.
If you have any questions regarding insurance coverage, please feel free to contact me at the Wilson Athletic
Center (386) – 822 - 7168 or an Athletic Trainer at (386) 822-8112.
Sincerely,
Glenn Brickey, MA, ATC, LAT
Director of Sports Medicine
I Type ____________
Date ____________
Office use only
Copy of Insurance
Card 
Stetson University
Athletic Department
Health Insurance Information Sheet
Sport: ________________
1) PROSPECTIVE STUDENT-ATHLETE INFORMATION
NAME: Last
First
Date of Birth:
Sex:
Middle
SSN# (last four digits only) :
M F
Local Address:
City:
State:
Zipcode:
Permanent Address:
City:
State:
Zipcode:
Phone:
(
(
Emergency Contact:
Phone (H)
Phone (W)
(
(
)
)
Phone:
)
)
2) PRIMARY INSURANCE COMPANY
Name of Insurance:
Policy or ID :
Subscriber:
Subscriber’s Date of Birth:
Insurance Company Address:
City:
State:
Insurance Company Phone:
Effective Date:
Expiration Date:
Relationship to subscriber:
child (c)
spouse (p)
self (s)
Group #:
Plan #:
Cov. Code:
Zipcode:
other (o)
3) PRIMARY INSURANCE COMPANY (2ND POLICY)
Name of Insurance:
Policy or ID :
Subscriber:
Date of Birth:
Insurance Company Address:
City:
State:
Insurance Company Phone:
Effective Date:
Expiration Date:
Relationship to subscriber:
child (c)
spouse (p)
self (s)
Group #:
Plan #:
Cov. Code:
Zipcode:
other (o)
I hereby certify that the foregoing answers are true, complete, and correct to the best of my knowledge. I also hereby authorize any
Insurance Company, Employer, Hospital, Physician, Surgeon, Pharmacy, or other health care provider to release any information with
respect to injury, treatment, or insurance. A photocopy of this authorization shall be considered as effective and valid as the original.
I will notify the Training Room of any changes in my insurance coverage within 30 days of said changes. I understand that if I do not
provide appropriate and complete information regarding any insurance claims I may be responsible for any outstanding medical bills.
_____________________________________________________________
_____________
Signature of Athlete (Parental signature required if under 18)
Date
I hereby certify that my son/daughter is NOT covered as an eligible dependent under an insurance plan.
____________________________
________________________________
_____________
Print Name (Parent)
Signature of Parent
Date
 In addition, please attach a scanned copy of your most
recent physical examination to this form. The physical
examination must be a copy of an official physical
examination form/documentation provided by your
physician ***