Johnson State College Sports Medicine
Sickle Cell Trait Waiver Form
About Sickle Cell Trait

Sickle Cell Trait is the inheritance of one gene for sickle hemoglobin and one for normal hemoglobin. Sickle Cell Trait will not turn into
the disease; it is a life-long condition that will not change over time. During periods of intense exercise, red blood cells containing the
sickle hemoglobin can change shape from round to quarter-moon, or “sickle.” Sickled red cells may accumulate in the bloodstream during
periods of intense exercise (2-3 minutes), blocking normal blood flow to the tissues and muscles. During periods of intense exercise,
athletes with sickle cell trait have experienced significant physical distress, collapsed, and even died. Heat, dehydration, altitude, and
asthma and other medical conditions may increase the risk for and worsen complications associated with sickle cell trait, even when
exercise is not intense. Common signs and symptoms of sickle cell emergencies include but are not limited to: increased pain and
weakness in the working muscles (especially legs/buttocks/low back); cramping type pain of muscles; soft, flaccid muscle tone; and/or
immediate symptoms with no warning signs.
Facts about Sickle Cell Trait





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Those at high risk are, ancestors from Africa, South or Central America, Caribbean, Mediterranean countries, India, and Saudi Arabia.
Sickle cell trait occurs in 8% of U.S. African Americans and 1 in 2,000 to 10,000 Caucasians.
Most dangerous risk is exertional rhabdomyolysis.
Dehydration worsens exertional sickling.
The harder and faster the athlete goes, the faster the onset. Training and rest should be modified.
A sickling collapse is a medical emergency.
Testing



The NCAA does not currently require testing at the Division III level but it is preferred at Johnson State College.
All individuals born after 1984 have been tested at birth for Sickle cell trait.
If no records from birth are available, sickle cell tests can be requested through your physician. The Sports Medicine Department at
Johnson State College may also assist you in acquiring the test at the Johnson State College Health Center. Payment for the test will be the
responsibility of the student-athlete (general cost is between $5-$35).
If you choose not to test for Sickle Cell Anemia, please complete the following waiver.
I, _________________________________________________, understand and acknowledge that the NCAA and
(Student-Athlete Name)
Johnson State College prefers that all student-athletes have knowledge of their sickle cell trait status. Additionally, I have read and fully understand
the aforementioned facts about sickle cell trait and testing.
Recognizing that my true physical condition is dependent upon an accurate medial history and full disclosure, I herby affirm that I have fully
disclosed in writing any prior medical history and/or knowledge of sickle cell trait status to the Johnson State College Sports Medicine Department.
I do not wish to undergo sickle cell trait testing as part of my pre-participation physical examination and I voluntarily agree to release, discharge,
indemnify and hold harmless the State of Vermont, the College, its officers, employees and agents from any and all costs, liabilities, expenses,
claims, demands, or causes of action on account of any loss or personal injury that might results from my non-compliance with Johnson State College
Intercollegiate Athletics.
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-Athlete Signature
_____________________
Date
_________________________________________________________
Parent/Guardian Signature (if under 18 years of age)
_____________________
Date
_________________________________________________________
Parent/Guardian Print Name
Johnson State College Sports Medicine
Sickle Cell Disclosure Form
I,
, affirm that I have been informed by my family physician as
to my Sickle Cell Trait Status and/or have undergone the sickle cell trait screening in the form of a blood test at the Johnson State
College Student Health Center.
1. Sickle Cell Trait Positive
Initial
2. Sickle Cell Trait Negative
Initial
About Sickle Cell Trait

Sickle Cell Trait is the inheritance of one gene for sickle hemoglobin and one for normal hemoglobin. Sickle Cell Trait will
not turn into the disease; it is a life-long condition that will not change over time. During periods of intense exercise, red
blood cells containing the sickle hemoglobin can change shape from round to quarter-moon, or “sickle.” Sickled red cells
may accumulate in the bloodstream during periods of intense exercise (2-3 minutes), blocking normal blood flow to the
tissues and muscles. During periods of intense exercise, athletes with sickle cell trait have experienced significant physical
distress, collapsed, and even died. Heat, dehydration, altitude, and asthma and other medical conditions may increase the risk
for and worsen complications associated with sickle cell trait, even when exercise is not intense. Common signs and
symptoms of sickle cell emergencies include but are not limited to: increased pain and weakness in the working muscles
(especially legs/buttocks/low back); cramping type pain of muscles; soft, flaccid muscle tone; and/or immediate symptoms
with no warning signs.
Facts about Sickle Cell Trait






Those at high risk are, ancestors from Africa, South or Central America, Caribbean, Mediterranean countries, India, and
Saudi Arabia.
Sickle cell trait occurs in 8% of U.S. African Americans and 1 in 2,000 to 10,000 Caucasians.
Most dangerous risk is exertional rhabdomyolysis.
Dehydration worsens exertional sickling.
The harder and faster the athlete goes, the faster the onset. Training and rest should be modified.
A sickling collapse is a medical emergency.
I, the undersigned, do hereby affirm that I have been informed of my sickle cell trait status by my family physician and/or one of the
clinicians at the Johnson State College Student Health Center. If my sickle cell trait status is positive, I understand that I am required
to undergo educational sessions around the topic of sickle cell and understand that specific precautions that need to be undertaken due
to the serious nature of the condition. The educational sessions will be administered by Johnson State College Sports Medicine
Department.
___________________________________________________
___________________
Student-Athlete Signature
Date
_______________________________________________________________ ________________________
Parent/Guardian Signature (if under 18 years of age)
Date
___________________________________________________
___________________
Examining Clinician Signature
Date
___________________________________________________
Examining Clinician Print Name
___________________________________________________
___________________
Athletic Trainer Signature
Date
___________________________________________________
Athletic Trainer Print Name