New/Transfer Student-Athlete Forms Checklist
PLEASE PRINT, COMPLETE, SIGN AND BRING THE FOLLOWING FORMS WITH YOU
TO YOUR PRE-PARTICIPATION PHYSICAL APPOINTMENT
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Student-Athlete Medical History
Athlete Insurance Form
Authorization to Release Form
Professional Scout Release Form
Acknowledgement, Acceptance, and Consent Form
Current copies of:
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Medical insurance card (REQUIRED, front and back)
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Dental coverage (if applicable)
____
Eye care coverage (if applicable)
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Prescription coverage (if applicable)
____
*Medical records (ADD/ADHD form/records, injuries, surgeries, etc)
*It is REQUIRED by the NCAA that we have current ADD/ADHD records and reports from
your treating physician, psychiatrist, and/or counselor. Please print the NCAA form (click here)
and have your treating health care professional complete the form and obtain the proper
documentation PRIOR to your pre-participation physical date.
Please retain this cover letter for your reference. If ANY of the above forms and documents are
not completed or are missing, you will not be able to participate in any UMKC athletic event,
including practice, weights/conditioning, games, etc., until fully completed. If you have any
questions, please do not hesitate to contact me. Thank you.
Ashley Riggs, MS, ATC
Assistant Athletic Trainer
5100 Rockhill Road
SRC 201
Kansas City, MO 64110
(816) 235-1382
Fax (816) 235-6591
Email: riggsac@umkc.edu
UMKC Student Athlete Medical History
The athletics staff at UMKC has a deep concern for the health and well being of each student-athlete. Please
complete this medical history completely. Please provide copies of your physician’s office notes and any
imaging studies (X-ray, MRI, etc.) for any medical conditions that required surgery or extensive monitoring
or treatment. If you are unsure if medical information is needed please call 816-235-1382.
Name ____________________________________ Birth date ____________________ Sport __________________
List any drug sensitivity or allergies: _______________________________________________________________
List all current medications: ______________________________________________________________________
Family History: (Yes or No)
____ Sudden death at a young age
____ Sickle cell disease or trait
____ Syncope (passing out)
____ High Blood Pressure
____ Heart disease or heart attack younger than 50 years old
Females Only:
____ Age of menses onset
____ Interval between cycles (#days/weeks)
____ Duration of cycle (# days)
____ Number of cycles in the last year
____ (Y/N) Oral Contraception for any reason?
____ (Y/N) History of irregular/missed cycles?
____ (Y/N) Abnormal Gynecologic Exam?
General Nutrition: (Yes or No)
____ Are you planning to start a diet or have you dieted in the last three months?
____ Do you feel pressure to change your weight?
____ Do you wish to gain or lose weight for any reason?
____ Do you feel your daily food intake is appropriate for the energy needed for your sport?
Do you have now or have you ever had: (Yes or No)
___ Allergic Reactions
___ Seizure/Epilepsy
___ Heat Exhaustion
___ Diabetes
___ Heat Stroke
___ Hernia
___ High Blood Sugar
___ Mononucleosis
___ Low Blood Sugar
___ Sickle Cell
___ Rheumatic Fever
___ Heart Murmur
___ Asthma
___ High Blood Pressure
___ Hepatitis
___ Pneumonia
___ Chest Pain
___ Tuberculosis
___ Anemia
___ Birth Deformities
___ HIV positive
___ Eating Disorder
___ Measles
___ Abnormal Heart Beat
___ Shortness of Breath
___ Heat Cramps
___ Depression
___ ADD/ADHD
___ Bipolar Disorder
___ Psychiatric Illness
___ Sprains
___ Fracture of a Bone
___Concussion
___ Surger
Please give details and dates:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
___________________________________________________________________________________________
Cardiovascular-Respiratory: Have you ever had lung disease? _____ Heart disease? _____
Physical activity limited because of a heart or lung condition? _____ Blood Pressure Medication? _____
Chest Pain or Shortness of Breath with Exercise? _____ Passed out during exercise? _____
Please give details and dates:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Name _____________________________________________________________
Sport ____________________
Genito-Urinary-Gastrointestinal: Have you ever had kidney disease or injury? _____
Liver disease or injury? _____ Enlargement or injury to the spleen? _____
Stomach or intestinal problems? _____ Unpaired/Missing Organs? _____
Undescended Testicle? _____
Please give details and dates:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Head and Neck: Have you ever had a head injury? _____ Concussion or “knocked out”? _____
Missed practice/games due to concussion? _____ Frequent headaches? _____
Vision impaired in either eye? _____ Do you wear glasses? _____ Contacts? _____ Do you have impaired
hearing? _____ Have you ever had fainting spells or convulsions/seizures? _____ Do you wear dental
implants?_____ Have you ever had a neck injury, ‘burner’ or ‘stinger’? _____
Please give details and dates:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Musculoskeletal: Have you ever dislocated a shoulder? _____ Separated a shoulder? _____ Bursitis?
_____ Had an elbow, wrist, or hand injury? _____ Arthritis? _____ Tendinitis? _____ Injured ligaments or
cartilage in your knee? _____ Severe ankle sprain? _____ Other ankle or foot injury? _____ Experience back
pain?_____ As a result of exercise? _____ Any fractures? _____ Any surgeries? _____ Any pins, screws, or
plates in your body as a result of surgery? _____ Any dislocations? _____ Do you have any chronic muscle
injuries? _____ Orthotics? _____ Shin Splints? _____ Stress Fracture? _____
Please give details and dates:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Have you ever been told by a doctor that you should not participate in any sport? ____________________________
Please give dates and details: _____________________________________________________________________
_____________________________________________________________________________________________
I certify that the above information is true to the best of my knowledge. I also understand that
UMKC is not liable for the care and costs of any medical expense due to pre-existing conditions
even if they have not been disclosed in the medical history or the physical examination.
Student-Athlete Signature ____________________________________
Parent’s Signature __________________________________________
(if student-athlete is under 18 years old)
Date _____________
Date _____________
UMKC ATHLETE INSURANCE FORM
Name (L, F, M) ____________________________________________ Sport _______ Class ___________
Cell Number _____________________________
Student ID __________________________________
Local Address __________________________________________________________________________
SS# ______-_____-_______
Birth date _____-_____-_____
Father/Guardian’s Name ______________________________________ SS# ________________________
Address ________________________________________ City, State, Zip __________________________
Employer ______________________________________ (H/C) Phone _____________________________
(W) Phone _____________________________________ Birth date _______________________________
Mother/Guardian’s Name _____________________________________ SS# ________________________
Address ________________________________________ City, State, Zip __________________________
Employer _______________________________________ (H/C) Phone ____________________________
(W) Phone ______________________________________ Birth date ______________________________
Athlete covered under which policy?
Yes or No:
Father ______
Is insurance an HMO? __________
Primary Care Physician (PCP) required?
Mother ______
PPO? ___________
Yes _____
Local PCP ___________________________________
Own ______
Other? ___________
No _____
PCP Phone # ________________________
PCP Address ___________________________________________________________________________
** Primary Care Physician must be in the Kansas City area **
Primary Coverage
Insurance Company ___________________________ Ins. Co. Phone # ____________________________
Claims Address ______________________________ City, State, Zip _____________________________
Insurance ID# ________________________________ Policy # __________________________________
Additional Coverage
Insurance Company ____________________________ Ins. Co. Phone # ___________________________
Claims Address _______________________________ City, State, Zip ____________________________
Insurance ID# ________________________________ Policy # __________________________________
Authorization to Release Information
Athlete’s Name ___________________________________ Sport _____________ Class ___________
SS# ______-_____-_______
Birth date _____-_____-_____
EMERGENCY CONTACT (if different from parental contact):
Name ________________________________
Relationship ___________________
Address ______________________________
Phone #: Home _________________
_______________________________
Work __________________
AUTHORIZATION TO RELEASE INFORMATION
I hereby authorize any physician, medical practitioner, hospital, clinic, other medical or
medically related facility, insurance company or their organization, institution, or person that has
any records or knowledge of the claimant’s physical health to give the information to the UMKC
athletic training staff, administrative staff and the UMKC secondary insurance company,
NAHGA Claim Services. To facilitate rapid submission of such information, I authorize all said
sources of such records or of such knowledge to collect and transmit such information to any
agency employed by the insurance company.
Student-Athlete’s Signature: _____________________________ Date: ______________
Parent/Guardian Signature: ______________________________ Date: ______________
(if student-athlete is under 18 years old)
UMKC Athletic Training
Acknowledgement, Acceptance and Consent Form
Insurance Acknowledgement
The undersigned, herewith:
Understands that any medical expense incurred due to preexisting conditions and not directly
attributable to intercollegiate athletics at UMKC is his/her responsibility.
Understands that any changes in primary insurance coverage must be communicated to UMKC in
a timely manner.
Understands that primary insurance coverage is required to participate in UMKC intercollegiate
athletics.
Understands that the athletics medical insurance is secondary coverage and does not cover the
student-athlete until he or she has been cleared by an athletics physical examination from the team
physician. This medical insurance only covers injuries where there is direct supervision by a UMKC
coach. It does not cover unsupervised workouts, intramurals or injuries sustained outside of athletics.
Understands that having passed the physical examination does not necessarily mean he or she is
physically qualified to engage in intercollegiate athletics, but only that the evaluator did not find a medical
reason to disqualify him or her from participation at the time of the examination.
Athlete’s Signature __________________________
Parent/Guardian Signature ___________________
(if athlete is under 18 years of age)
Date __________________
Date __________________
Acceptance of Risk
I understand that participation in sports requires an acceptance of risk of injury. I understand that I
may be injured permanently (paraplegia, quadriplegia, muscle or tendon injury, and surgeries of various
types) while participating in sports and accept the risk. Catastrophic injuries such as death or loss of organs
may occur during sports participation. I understand that I must follow the rules of my sport. I understand
that I must refrain from practice or play while injured or ill, whether or not receiving treatment, and during
medical treatment, until I am discharged or given permission by the team physician to restart participation
despite continuing treatment.
I understand that I accept the responsibility for reporting all my injuries and illnesses, including all
signs and symptoms of concussions, to the UMKC Sports Medicine staff.
Athlete’s Signature __________________________
Parent/Guardian Signature ___________________
(if athlete is under 18 years of age)
Date __________________
Date __________________
Consent for Treatment
I understand that I may be injured while participating in athletics at UMKC. I authorize the school
to obtain through a physician of its choice any emergency or routine medical care that may become
necessary as a result of being injured while participating or traveling under UMKC supervision. I authorize
the UMKC athletics trainer to administer those treatments deemed necessary by the team physician while
acknowledging that no guarantees have been made as to the results of the examination(s) and treatment(s).
Athlete’s Signature __________________________
Parent/Guardian Signature ___________________
(if athlete is under 18 years of age)
Date __________________
Date __________________
Upon completion of this form it is to be reviewed and signed by a UMKC Athletic Trainer.
Signature _________________________________
Date
__________________
PROFESSIONAL SCOUT RELEASE
I, the undersigned, do hereby authorize the UMKC athletics training staff to release,
verbally and/or in writing, to professional scouts and professional clubs for purposes
related to my future employment, my yearly medical history/physical examinations, all
athletics injury reports and records, and correspondence between the team physician
and/or attending physician and the athletics trainers.
Athlete’s Signature: ___________________________________
Date: ____________
Parent/Guardian Signature: _____________________________
(if student-athlete is under 18 years of age)
Date: ____________