| Cobber Athletic Home | Returning Athlete Update Form | First Year Preparticipation Health History |
Concordia College Emergency/Insurance Information
Please print form, fill out completely and return
to:
Stephanie Brandt - Athletic Trainer
Concordia College
901 South 8th Street
Moorhead, MN 56562
| Athlete's Name | Date of Birth | |||
| Last, First, MI | ||||
| Sports Participating in | ||
| Social Security # | ||
| College Address | Phone # | |
| Parent/Guardian Name | Phone # | |
| Address | ||
| EMERGENCY CONTACT IN NO ANSWER ABOVE | ||
| Name | ||
| Relationship | Phone # | |
| Known Allergies | Last Tetanus Booster | |
| Current Prescriptions | ||
| Significant Midical Conditions | ||
| INSURANCE INFORMATION | |||
| Name of Policy Holder | |||
| Company | |||
| Group # | |||
| Policy/ID# | |||
| Mailing Address (for claims)
Street City State Zip 800 Phone # |
|||
| Do you have insurance restrictions as to a physician you can see? Yes No | |||
| If yes, which group of physicians can you see? Orthopedic Associates Merit Care Dakota/Innovis | |||
| Do you have insurance restrictions as to where you need to receive physical therapy? Yes No | |||
| If yes, which group of physical therapists can you see? Health South Merit Care Dakota/Innovis | |||
| Medical Authorization This
athlete/parent gives consent for the team physician, consulting physician
and/or appropriate member of the sports medicine staff of Concordia College
to examine records, or be in consultation concerning examination or treatment
of the athlete for the express purpose of evaluating the medical and/or
physical fitness for participation in, or continued participation in any
athletic program at Concordia College. The athlete/parent also gives
permission for acceptable diagnostic, therapeutic and emergency operative
procedures to be carried out in the treatment of illness and injury sustained
while a member of a Concordia College athletic team.
|
| Athletic Insurance Policy
Athletic insurance is provided by Concordia College for the benefit of our intercollegiate student-athletes. For the 2001 -- 2002 school year, athletic insurancecoverage is provided by ReliaStar Life Insurance company and administered by Student Assurance Services. This coverage is offered on an "excess" basis only, which means ReliaStar Life Insurance Company will only cover expenses after the athlete's primary carrier has been used to its fullest extent. Primary coverage would include parental insurance under which the student-athlete is covered as an eligible dependent. The deductible for this insurance policy is $500 per injury. If the student-athlete is injured in a separate incident at a later date, he or she will be required to pay another $500 deductible before ReliaStar Life Insurance will begin to cover expenses. All claims must be filed within 30 days of injury. The above statements are true to the best of my knowledge.
This athlete gives consent for the team physician, consulting physician,
Concordia Student Health Personnel and/or appropriate member of the sports
medicine staff of Concordia College to examine records, or be in consultation
concerning examination or treatment of the athlete for the express prupose
of evaluating the medical and/or physical fitness for participation in,
or continued participation in any athletic program at Concordia College.
The athlete/parent also gives permission for acceptable diagnostic, therapeutic
and emergency operative procedures to be carried out in the treatment of
illness and injury sustained while a member of a Concordia College Athletic
Teams.
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