Athletics Consent Form

I hereby authorize Drew University and/or their insurance administrator to inspect or secure copies of my case history records, diagnosis, x-rays or other radiographic materials, and any other needed information, including enrollment verification, concerning current or previous injuries and/or previous confinements or disabilities.

I authorize the Drew University insurance administrator to pay the medical providers for any bills incurred from athletic injuries or accidents that are covered expenses under the insurance policy purchased by Drew University. I understand that Drew reserves the right to change the existing insurance policy annually.

Further, I authorize the athletic trainers and collaborating physicians employed or contracted by Drew University Athletic Department to assess, treat, rehabilitate and refer me if necessary during the year. I further authorize these health care professionals to disseminate information concerning any athletic injury or health status to the appropriate athletic department staff members on a need to know basis. In addition, I hereby authorize the Athletic Department trainers and their collaborating physicians to divulge information about any injury or illness to Drew Health Service, or to outside professionals who are involved in my care. I also authorize the health care professionals from Drew Health Service to divulge information regarding any relevant health condition to the athletic trainers and physicians, and to any outside consultants who are concerned with my care.

I accept the risk that accompanies participating in any sport at Drew University. I fully understand that at any time during my participation that I might be injured. The injury may be severe and may be season or career ending. I also understand that by engaging in athletics I may incur such injuries that include, but are not limited to: severe head and neck injuries, paralysis, or death.

I understand that intercollegiate sports injuries are now covered by the Drew Student Insurance Plan up to $1,000. I further understand that if an intercollegiate athlete is also covered under a parent’s plan, the parent plans pays first, and the student plan pays second. When costs exceed $1,000, the Drew Athletic Insurance Policy (which is a different policy than the basic student insurance plan and is paid for by Drew) will pay second after the parent plan up to the next $65,000, or first when the student insurance plan is the student’s only insurance. In the unlikely event of an extreme injury, the NCAA catastrophic insurance will cover costs that exceed $65,000.  (Beginning in fall 2005, the Drew Athletic Insurance Policy will cover expenses up to $75,000.)

I understand that I am responsible for all medical bills related to the treatment of injuries that may occur as a result of my participation in sports at  Drew University. I further understand that Drew University does not accept responsibility for any of these charges.

A photostatic copy of this authorization shall be deemed as effective and valid as the original.

I have read and completely understand the above and give my consent for all that is listed.

Athlete’s Signature ___________________________________Date______

Print name here _____________________________

Parent/Guardian _________________________________________Date______

(only if student is not 18 years old)