Club Sports Documentation Student Activity Association (SAA) – East Stroudsburg University
The Following Packet is the Required Documentation for All Club Sports Members and Officers. INSTRUCTIONS: 1. READ AND COMPLETE ALL DOCUMENTS (front and back) 2. Players are not eligible to practice or work-out until they return ALL forms to their Club President 3. In the event your Health/Accident Insurance is discontinued for any reason, please contact the Assistant Director of Club Sports immediately: Lauren Motzkin Recreation Center, Room 115 (570) 422-2968
[email protected] NOTE: • All members and officers must have a University Health Services Health Form on file to participate in Club Sports. • Any members found on University Probation, or to have a University Suspension, will not be granted eligibility.
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Health/Accident Insurance & Information Student Activity Association (SAA) – East Stroudsburg University Policy for the participation in Club Sports requires every participant have Health/Accident Insurance Coverage. Evidence of such coverage must be made known to the club sport president, who will then inform the Assistant Director of Club Sports, so that they are prepared to respond appropriately if the need arises. This form must be completed by each participant at their first club meeting or before their first practice with team, and each semester following. All players must also have a University Health Services Health Form on file to participate in club sports.
Participant’s Information: Name: _______________________________________________ Last 6 digits of eCard: Class Year:
Freshman
Sophomore
Junior
Senior
Email: _______________________________
Phone: (_______) _______ - ___________
Local Address: ________________________
City: ____________________ State: ______
Grad
Zip: ________
Emergency Contact Information: Name: _______________________________
Relationship: _________________________
Address: _____________________________
City: ____________________ State: ______
Home Phone: (_______) _______ - ___________
Zip: ________
Cell Phone: (_______) _______ - ___________
Any limiting physical disabilities or handicaps (temporary or permanent): Yes _______ No _______ If yes, please explain: ______________________________________________________________________
Currently taking medication (prescribed or over the counter): Yes _______ No _______ If yes, please state medication: _______________________________________________________________
Allergies, reactions to medications or other medical limitations: Yes _______ No _______ If yes, please explain: ______________________________________________________________________
Insurance Coverage: Company Name: _______________________________________________________ Policy Number: _______________________________ Expiration Date: ______/______/________
I understand that I cannot participate in the _________________________________________________ (Student Organization) unless I have health/accident medical coverage. I herein certify that I will notify the SAA Accounting Office or the Assistant Director of Club Sports if this coverage is discontinued for any reason. Participant’s Signature: X_________________________________________
Date: _____/_____/_______
Parent/Guardian Signature (if under 18): X_____________________________________________________ Print Parent/Guardian Name: X_____________________________________
Date: _____/_____/_____
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Informed Consent Release Waiver & Expressed Assumption of Risk Student Activity Association (SAA) – East Stroudsburg University I, _____________________________________________________________, desire to participate in the (Student Name, Please Print, USE PEN ONLY) _____________________________________________________________, Fall 20_____ or Spring 20 _____ (Student Organization) I realize that this SAA program operates with volunteer nonprofessional instructors. I also realize that injuries are an inevitable consequence of participating in physical activities and that no amount of reasonable coaching, instruction, use or proper equipment, or facilities will prevent all injuries. I realize, and understand, that severe injuries are possible even from sports which have little or no body contact. I understand and appreciate that such injuries can range from the most insignificant to death; serious neck and spinal injuries which may result in partial or total paralysis; brain damage; loss of sight, hearing, sense of smell; serious and permanent injury to all bodily organs and functions; serious injury to general health and well being. I realize that my use of vehicular transportation to and from sporting activities, whether participating as a driver or passenger, and whether using either SAA-supplied vehicles or vehicles of private individuals, although not an inherently dangerous activity, nonetheless, also entails risks or injury to persons, and to property. I understand and am aware that I will be responsible for my actions and conducting myself as outlined in the ESU Student Code of Conduct. I am aware of the existence of the risks that I take. I appreciate their character and voluntarily assume all risks of harm. I have carefully considered how the possible consequences of injury may impact my life, and I chose to accept these risks and participate in the ______________________________________________________________________________________________ (Student Organization) In accepting these risks, I expressly and explicitly release, discharge and waive any and all responsibility of East Stroudsburg University of Pennsylvania, and the Pennsylvania State System of Higher Education, The East Stroudsburg University Student Activity Association, or the employees, officials, or agents of any of the foregoing, pursuant to, or pertaining, or rising from, in any matter, injuries to my person and property as a result of my participation in the ______________________________________________________________________________________________ (Student Organization) Participant’s Signature: X _____________________________________ Date: ______/______/______ FOR PARTICIPANTS OF MINOR AGE This is to certify that I, as parent/guardian with legal responsibility for this participant, do herewith consent and agree to his/her release as provided above, of all the Releases , and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify the Releases from any and all liabilities to my minor child’s involvement or participation in SAA sponsored club activities and programs as regards the provisions of transportation, unless arising from the recklessness and wanton disregard of the Releases. Parent/Guardian Signature: X______________________________________
Date: ______/______/______
Print Parent/Guardian Name: _____________________________________ Emergency Telephone Number: (________) ________ - ____________ A3
The East Stroudsburg University Student Activities Association, Inc. (the “SAA”), in its sponsorship of various student club activities and programs, sometimes licenses the use of its and mini-vans (its “vehicles”), or provided reimbursement for traveling expenses where private individuals provide their own means of transportation, to participants in those activities and programs. Prior to and as a condition of its permitting the use of its vehicles, or of providing reimbursement for traveling expenses, the SAA shall require the sponsored club to provide a roster of all club members, none of whom shall be under 18 years of age unless otherwise provided by the SAA, who shall be utilizing those vehicles, whether supplied by the SAA or by a club member, along with emergency contact numbers for all individuals listed upon the roster and a Waiver and Release executed by those individuals. Furthermore, as part of that Waiver and Release, club participants who provide their own vehicular transportation shall acknowledge that their private insurance provides primary coverage with respect to all risks, and any insurance coverage provided by the SAA is secondary to that primary coverage. Failure to abide by these conditions, as well as the ESU Student Code of Conduct, may result in a denial of further use of the vehicles by the sponsored club, and/or denial of reimbursement for the sponsored club’s past and future traveling expenses. I, _____________________________________________________________, desire to participate in the (Student Name, Please Print, USE PEN ONLY) _____________________________________________________________ Fall 20_____ or Spring 20 _____ (Student Organization) I realize that vehicular transportation to and from SAA sponsored activities, whether participating as a driver or passenger, and using vehicles supplied by the SAA or by private individuals, although not an inherently dangerous activity, nonetheless, also entail risk of injury to the persons, and to property. I understand the conditions regarding the use of vehicles, whether supplied by the SAA or private individuals, in SAA sponsored club activities and programs, as aforesaid, and will abide by the same, and accept the consequences as heretofore provided. In accepting these risks, I expressly and explicitly release, discharge and waive any and all responsibility of East Stroudsburg University of Pennsylvania, and the Pennsylvania State System of Higher Education, the East Stroudsburg University Student Activity Association, or the employees, officials, or agents of any of the foregoing, pursuant to or pertaining, or rising from, in any matter, injuries to my person and property as a result of my participation in the: ____________________________________________________________________________________________ (Student Organization) Signature: X __________________________________________
Date: __________________
FOR PARTICIPANTS OF MINOR AGE This is to certify that I, as parent/guardian with legal responsibility for this participant, do herewith consent and agree to his/her release as provided above, of all the Releases , and for myself, my heirs, assigns, and next of kin, I release and agree to indemnify the Releases from any and all liabilities to my minor child’s involvement or participation in SAA sponsored club activities and programs as regards the provisions of transportation, unless arising from the recklessness and wanton disregard of the Releases. Parent/Guardian Signature: X______________________________________________ Print Parent/Guardian Name: _________________________________________
Date: ______/______/______
Emergency Telephone Number: (________) ________ - ____________
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HAZING Policy 1. All activities of a club sport should be positive in nature. 2. Recruitment of new members should be based on interest and dedication to the organization and not based on anti-discriminatory basis defined by the University and/or the Commonwealth of Pennsylvania. 3. The term HAZING shall include, but not be limited to: o Any action or situation which recklessly or intentionally endangers the mental or physical health or safety of a student or which willfully destroys or removes public or private property for the purpose of initiation or admission into or affiliation with, or as a condition for continued membership in any organization operating under the sanction of, or recognized as, an organization by an institution of higher education. The term shall include but not be limited to any brutality of a physical nature, such as whipping, beating, branding, forced calisthenics, exposure to the elements, forced consumption of any food, liquor, drug or other substance, or any other forced physical activity which could adversely affect the physical health and safety of the individual, and shall include any activity which would subject the individual to extreme mental stress, such as sleep deprivation, forced exclusion from social contact, forced conduct which could result in extreme embarrassment, or any other forced activity which could adversely affect the mental health or dignity of the individual. 4. Pennsylvania Act 175 of 1986 states that no student can consent to being hazed. Any activity falling within the definition of hazing is considered to be a forced activity, subjecting the organization/athletic team and its members to the full range of penalties. 5. Any club found to be hazing will be subject to investigation by the Office of Student Conduct and Community Standards. Hazing Agreement: 1. I have read and understand the hazing policy for East Stroudsburg University. 2. I verify that all activities sponsored, conducted or required by our club comply with this policy. 3. Failure of my club to follow this policy will result in referral as an organization or individual to student conduct. By signing this form I acknowledge and agree to the Hazing Policy guidelines stated above. Club Sport______________________________ Member Name (Print)_____________________________________________ Signature_______________________________________________________ Date__________________________________________
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Name: ___________________________________________
Date of Completion: ______/______/______
Club Sport: _______________________________________
Date of Birth: ______/______/______
Email Address: ____________________________________
Local Phone: (_______) _______ - _________
Emergency Contact Name: ______________________________ Relationship: _______________________ Emergency Contact Phone: (Home) (______) _______ - _________
(Cell) (_______) _______ - _________
Insurance Company: _______________________________________________________________________ Policy Number: ___________________________________________________________________________ PLEASE COMPLETE THE FOLLOWING MEDICAL INFORMATION
Have any of the following occurred since your last physical or medical exam? If yes, please list/explain. 1. Had any illness? Yes No __________________________________________ 2. Taken medication? Yes No __________________________________________ 3. Been hospitalized? Yes No __________________________________________ 4. Been unconscious for any reason? Yes No __________________________________________
Please indicate any injuries that you have had in the past 2 years. If yes, please explain.
Body Part
Yes
No
Explain
Head Shoulder Arm/Hand Neck Ribs
5. Do you have allergies? Yes No __________________________________________
Back
6. Asthma or Trouble Breathing? Yes No __________________________________________
Hip
7. Taken any supplements? Yes No __________________________________________
Thigh
8. Reactions to Medications? Yes No __________________________________________
Knee Leg Ankle/Foot
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Have any of the following occurred since your last physical or medical exam? If yes, please list/explain. 1. Have you ever suffered a heat related illness and/or received intravenous (IV) fluids for heat related problems? YES NO _____________________________________________________________ 2. Have you ever been diagnosed with diabetes? YES
NO
_____________________________________________________________
3. Have you ever had chest pain and/or unexplained shortness of breath during or after exercise or practice? YES NO ______________________________________________________________ 4. Have you ever felt dizzy, lightheaded and/or passed out during or after exercise/practice? YES NO ______________________________________________________________ 5. Have you ever had a feeling of your heart racing or skipping beats during or after exercise/practice? YES NO ______________________________________________________________ 6. Do you get tired more quickly than your teammates/friends do during exercise/practice? YES NO ______________________________________________________________ 7. Have you ever had a heart murmur? YES NO ______________________________________________________________ 8. Has any family member or relative died of heart problems and/or of sudden death before age 50? YES NO ______________________________________________________________ 9. Has a physician ever denied or restricted your participation in sports due to any heart problems? YES NO ______________________________________________________________ 10. Do you cough, wheeze, or have trouble breathing during or after exercise/practice? YES NO ______________________________________________________________ 11. Have you ever had seizures or convulsions? YES NO ______________________________________________________________ 12. Do you or anyone in your family have sickle cell trait or disease? YES NO _______________________________________________________________ 13. Any limiting physical disabilities or handicaps (temporary or permanent) YES NO _______________________________________________________________ I hereby state that, to the best of my knowledge, my answers to the above questions are true and complete. Signature of Participant: X _____________________________________
Date: ______/______/______
Signature of Parent/Guardian (if under 18): X __________________________________ Print Parent/Guardian Name: ___________________________________
Date: ______/______/______
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CLUB SPORT DISCIPLINARY CHART Assistant Director of Recreation Center Infraction/Violation Disciplinary
Warning
Temporary Suspension of Facility Usage
Failure To Reserve Facilities Failure To Provide Requested Documentation
X X
X X
Failure To Maintain Minimum Roster Failure To Attend Mandatory Meetings Failure To Submit Required Paperwork Loss Of SAA/University Equipment Failure To Follow SAA Financial Policies
X
Failure To Meet Established Deadlines Failure To Maintain Accurate Roster Failure To Maintain Facility Policies Unapproved Travel Poor Sportsmanship Fighting Or Inappropriate Contact Team International Travel Abuse/Damage To SAA/Univ Property Off-Campus Violation Discrimination, Harassing, Or Hazing Behavior
X
X
X
X
X
X
X
SAA/Student Affairs
Student
Individual Suspensions
Frozen Funds
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X X
X
Loss of Suspension SOCS Club or Disciplinary Privileges Removal of Club
X
X
X
X
X
X
X
X
X
X
X X X
X X X X
X
X X
X X
X X
Alcohol Violation X X Drug/Controlled Substance X X Violation Violations listed in bold do not require a warning, and could result in immediate suspension of the club until further action has been determined through the Assistant Director of Club Sports, SAA, Student Senate and Student Conduct. Signing below signifies that I have read and understand the stated violations and consequences list. Name_______________________________________ Signature___________________________________ Date___________________ A8
East Stroudsburg University Club Sports Concussion Information and Agreement Form WHAT IS A CONCUSSION? A concussion is a brain injury that: • Is caused by a blow to the head or body • Can change the way your brain normally works • Presents itself differently for each athlete • Can occur during practice or competition in any sport or outside of sport • Can happen even if you do not lose consciousness WHAT IS SECOND IMPACT SYNDROME? • Second impact syndrome is a rare condition in which a second concussion occurs before a first concussion has properly healed • Causes rapid and severe brain swelling and often catastrophic results • In many cases, second impact syndrome is fatal. In those cases where it is not fatal, you can expect long-term effects due to traumatic brain injury. • The second impact causing the second concussion does not have to be severe to cause this fatal condition YOU CAN HELP PREVENT CONCUSSIONS BY: • Not initiating contact with your head • Avoiding striking an opponent in the head. Undercutting, flying elbows, stepping on a head, checking an unprotected opponent, and sticks to the head can all cause concussions. • Practicing good sportsmanship at all times WHAT ARE THE SYMPTOMS OF A CONCUSSION? Symptoms can occur immediately, hours, or days after injury. Exercise or activities that involve a lot of concentration such as studying, working on computer, watching television, or playing video may cause concussion symptoms to reappear or worsen. It is important to update the athletic trainer on changing or worsening symptoms as soon as possible. • Amnesia • Confusion • Headache • Loss of consciousness • Balance problems • Dizziness • Double/fuzzy vision • Nausea • Feeling sluggish, foggy, or groggy • Feeling irritable/personality change • Concentration or memory problems • Slowed reaction time
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WHAT SHOULD I DO IF I THINK I HAVE A CONCUSSION? Don't hide it. Tell your athletic trainer. Never ignore a blow to the head. Also, tell your athletic trainer if one of your teammates might have a concussion. Sports have injury timeouts and player substitutions so that you can get checked out. Remove Yourself. Do not return to participation in a game, practice or other activity with symptoms. The sooner you get checked out the sooner you may be able to return to play. Get checked out. Your team physician, athletic trainer, or health care professional can tell you if you have had a concussion and when you are cleared to return to play. A concussion can affect your ability to perform everyday activities, your reaction time, balance, sleep, and classroom performance. Take time to recover. If you have had a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have a repeat concussion. In rare cases, repeat concussions can cause permanent brain damage and even death. Severe brain injury can change your whole life.
East Stroudsburg University Club Sport Concussion Information Agreement: I, _______________________________ have read and fully understand the presented facts about concussions. I hereby affirm that I have, and will, fully disclose any prior medical injuries and illness regarding signs and symptoms of concussions to East Stroudsburg University Club Sports Athletic Trainer/Sports Medicine personnel. 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. If I am under the age of 18, my legal guardian will also sign this form. __________________________________ Student-Athlete Signature __________________________________ Sport __________________________________ Parent/Guardian Signature (if under 18 years of age)
_______________ Date
_______________ Date
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