For All Student-Athletes

Chemeketa

Community College

Athletic Sports Packet

For All Student-Athletes

Sport Programs

Baseball Men

Basketball Men & Women

Soccer Men & Women

Softball Women

Volleyball Women

Sports Programs

Athletic Office: Bldg. 7-103 Phone # (503) 399-5081

Fax # (503) 399-5496

Athletic Director: Cassie Belmodis Phone # (503) 399-5159

Fall

Men’s Soccer

Head Coach: Marty Limbird (503) 399-5030

Women’s Soccer

Head Coach: Megan Moore (503) 312-8941

Volleyball

Head Coach: Traci Stephenson (503) 807-7177

Winter

Women’s Basketball

Head Coach: Jesse Ailstock (503) 877-7227

Men’s Basketball

Head Coach: David Abderhalden (503) 399-2554

Spring

Men’s Baseball

Head Coach: Nathan Pratt (503) 399-7953

Women’s Softball

Head Coach: Alisha Bowen (503) 917-1330

Dear Parents:

Thanks for becoming a part of the Chemeketa athletic family.

We urge you to read the material in this packet so you may be aware of Chemeketa Community College’s Medical Coverage as it applies to your student/athlete.

We need you and your athlete to fill out all the information in this packet and return it to the appropriate coach before the first practice date.

Thanks for being a part of the CCC athletic team.

Sincerely,

Cassie Belmodis

Athletic Director

JN

Welcome to the Chemeketa Community College

Athletic Program

This sports packet of materials contains a number of forms that must be completed in order to participate in the Chemeketa athletic program. All forms must be completed and returned to your coach on or before the first day of practice.

The first part of the packet contains intercollegiate athletic accident insurance information. Please keep all this information for future reference.

All athletes must complete the following forms:

1. Intercollegiate Athletic Coverage (requires signatures)

2. Emergency Information Sheet

3. Athlete Primary Insurance Information Form

4. Measles Immunization Requirement

5. NWAACC Athletic Questionnaire/Recruiting Disclaimer

6. Student/Athlete Physical Form – Personal

7. Physical Examination – by Physician

All student-athletes must have a physical every two years and the form must be turned in before the first day of practice for your sport.

Transfer Students only must complete the NWAACC Tracer Report Form. (It can be faxed from CCC Athletic office to previous colleges).

An official transcript from previous colleges must be mailed to Chemeketa Admission's office.

Every student has the responsibility to update all forms as necessary.

CHEMEKETA

COMMUNITY COLLEGE

M E M O

TO: STUDENT ATHLETES AND THEIR PARENTS

RE: ATHLETIC TEAM ACCIDENT GROUP COVERAGE

The college provides accident insurance for intercollegiate athletes. This coverage is only for accidental injuries sustained during team practice, play in a regularly scheduled game, and group travel to and from games or practices.

The plan does not cover medical expenses for sickness or accidental injuries sustained outside the student’s performance as a member of an eligible Chemeketa athletic team.

Benefits are payable after satisfaction of a $250 deductible per injury and after other available group insurance benefits have been paid. Claims must be submitted to other group plans for reimbursement before they are submitted to this plan for consideration. If no other insurance exists, claims should be sent directly to this plan.

Benefits in the Basic Plan are based on reasonable and customary fees charged by providers in the Salem, Eugene, and Portland areas. Since some medical expenses may not be reimbursed by this plan, parents are urged to keep eligible dependent children covered on their employer’s group medical, dental, or vision plans as long as possible.

Plan brochures and claim forms may be obtained from the team coach or the Physical Education Department in Building 7. Inquiries regarding coverage or claims should be directed to the claims administrator as listed below:

SUMMIT AMERICA INSURANCE SERVICES, L.C.

7400 College Boulevard, Suite 100

Overland Park, KS 66210

Phone: 877-246-6997

Fax: 913-327-7520

Chemeketa Community College

Intercollegiate Athletic Coverage

TO: Chemeketa Athletes

RE: Athletic Injuries

The college provides accident insurance for students participating in intercollegiate athletic programs. This is SECONDARY coverage for any athlete who is covered by another plan. The policy has a $250 deductible per injury.

All Athletic injuries, whether occurring on or off campus, must be reported immediately to your coach.

1.  According to Chemeketa Board of Education policy, all athletes are covered by a $250 deductible secondary accident insurance plan for injuries that occur during a Chemeketa sponsored athletic event.

2.  All athletes will IMMEDIATELY report injuries to their coach. Athletes will report to their coach at least weekly while undergoing treatment and until a written release from the doctor is received.

3.  Athletes will complete the insurance claim form and provide required information about primary insurance coverage which is provided through parents’ employment.

4.  Insurance forms are available from the coach or the Athletic Department.

5.  Athletes will be responsible for non-insured medical expenses.

6.  Athletes will be responsible for sending the completed claim form, medical bills and primary Insurance company payment statements to the claims administrator, Summit America Insurance Services, 7400 College Blvd., Suite 100, Overland Park, KS 66210, Phone (toll-free) 1-877-246-6997. Medical bills not submitted to the claims administrator will not be paid by the college.

7.  Athletes will be responsible for billing their primary insurance carrier for maximum benefits before the college insurance plan makes any payments.

I have read and understand the above insurance policides/procedures of the Chemeketa Community College intercollegiate athletic program.

/ /

Student Signature Date Parent Signature Date

Student Printed Name Parent Printed Name

4000 Lancaster Drive NE / PO Box 14007 / Salem, Oregon 97309-7070 / PHONE: 503-399-5081

Date ______Sport ______

Chemeketa Athletic Department

Emergency Information

Name: Birth Date: Age:

Parents or Guardian Name:

Address:

Home Phone: Work Phone:

In case of an emergency, if parent/guardian cannot be contacted:

Notify: at:

Name Telephone Number

Are you allergic to any medications? Yes_____ No_____

If yes, what?

Are you diabetic? Yes_____ No_____

Name of Insurance: Insurance Group Number: _

Parent/Guardian Medical Release

If, I (parent/guardian) ______cannot be contacted in the event of an emergency,

I give permission for ______(coach) to make medical decisions for my child.

Athlete Primary Insurance

Information Form

Athlete Information:

Name:
Social Security Number:
Campus Address:
Telephone:
Family Information:
Father's Name:
Social Security Number:
Occupation:
Address:
Home Address:
Telephone:
Employment:
Employer Address:
Employer Telephone:
Insurance Carrier:
Carrier Address:
Insurance Group Number:
Mother's Name:
Social Security Number:
Occupation:
Address:
Telephone:
Employment:
Employer Address:
Employer Telephone:
Insurance Carrier:
Carrier Address:
Insurance Group Number:
Insurance athlete is covered under:

New and Transfer Chemeketa

Student Athletes Community College

Certificate of Immunization Status

Document of Verifying Measles Protection

Instructions:

Students who are born on or after January 1, 1957, involved in clinical experiences in nursing or allied health programs, practicum experiences in education or child care programs, certain work experience programs, and membership on intercollegiate sports teams must have two doses of measles vaccine prior to participation. Proof of immunization must be provided or a properly documented religious or medical exemption signed. For information about what constitutes proof of immunization, consult your advisor.

The Student

Last Name First M.I.

Street Address City

County Zip Telephone

S.S.# Sex Birth Date (mo/day/yr)

Section A Section B

Vaccine History Religious Exemption

I have read and understand the information

Vaccine Dose Mo. Day Yr. Initial Date below about the risks of nonimmunization.

I am an adherent to a religion the teachings

Measles 1 of which are opposed to immunization, and

I request that I therefore be exempted from

2 immunization requirements.

______

Health Care Professional Verification Signature Date Signature Date

Section C

Medical Exemption

I certify that the above-named student should be exempted from the requirements for the measles vaccine.

Based on:

n History of disease (mo/yr)

n The following reason which constitutes a medical contraindication in accordance with the Advisory Committee on immunization Practices of the U.S. Public Health Service for the vaccine(s) indicated:

Health Care Professional (Please print) Phone

Signature of Health Care Professional (MD ND DO NP) Date

Risks of Nonimmunization

Immunization is a safe and effective way to protect against vaccine-preventable diseases that can hurt, cripple, and even kill.

Measles is a serious disease characterized by rash and moderate to high fever. It can lead to pneumonia, serious ear infections, deafness, convulsions, inflammation of the brain, and even death. Severe complications develop in one out of each thousand cases. One in ten of such complicated cases will result in death. Measles can spread rapidly among nonimmunized people in a group situation such as a school day care center practicum site.

Students with religious or medical exemption(s) (except a verified history of disease) are not protected against the disease, which means that they are at risk of getting the disease. In the event of an outbreak, students with a religious or medical exemption for the particular disease may be excluded from their student placements in health care, education, or childcare settings or from their participation in sports competition.

Immunizations are vital to your good health. When immunization levels go down, disease levels go up.

Chemeketa Community College

P.O. Box 14007

Salem, OR 97309

Student/Athlete Personal Medical History

PLEASE CAREFULLY AND COMPLETELY READ THE FOLLOWING INFORMATION

Completion of this medical history and examination form is mandatory for participation in the sports programs of this college. Please make sure that all statements regarding your personal information and medical history is complete and accurate.

NWAACC Regulations state: After July 1st and prior to the first practice of each year of participation in intercollegiate athletics at a member college, a student-athlete shall undergo a medical examination and be approved for intercollegiate athletic competition by a medical authority licensed to perform a physical examination by the laws applicable in the state where the exam is conducted. Those licensed and approved to perform physical examinations include Medical Doctors (M.D.), Doctors of Osteopathy (D.O.), Certified Registered Nurses (C.R.N.), Naturopaths (N.D.) and Physician's Assistants (P.A.).

This form is to be completed and signed by the student or, if the student is under the age of 18, by the student's parent or guardian. Any Information withheld or falsified may affect the student's status on the athletic team and/or the student's scholarship funding. The college reserves the right, with the student's authorization, to request past medical records, charts and diagnoses regarding injuries, medical history or physical condition, and may request additional medical examinations or tests if indicated.

NWAACC (2004) Page 1 of 6

YOUR LAST PHYSICAL EXAMINATION

Date ______Doctor's name ______City, State ______

Please list any abnormalities found on any past physical examinations ______

______

IMMUNIZATION RECORD

Measles* / q Yes / q No / Date of last shot / ______
Mumps* / q Yes / q No / Date of last shot / ______
Rubella* / q Yes / q No / Date of last shot / ______
Polio / q Yes / q No / Date of last dose / ______
Tetanus (Td) / q Yes / q No / Date of last shot / ______

*Note: These are commonly noted on immunization records as "MMR" and often given as one shot.

A second dose of measles vaccine is recommended for college entrance.

FAMILY MEDICAL HISTORY

Please check YES or NO in appropriate box.

1. / q Yes / q No / Osteoporosis / 5. / q Yes / q No / Hemophilia
2. / q Yes / q No / High blood pressure / 6. / q Yes / q No / Diabetes
3. / q Yes / q No / Neuromuscular disease / 7. / q Yes / q No / Anemia
4. / q Yes / q No / Sudden death from heart disease or stroke / 8. / q Yes / q No / Cancer

If living, please check box to signify family member's general health. If deceased, please state age and cause of death, if known.

Age at Death Cause of Death
Father / q Excellent / q Good / q Fair / q Poor / q Deceased / ______
Mother / q Excellent / q Good / q Fair / q Poor / q Deceased / ______
Brother #1 / q Excellent / q Good / q Fair / q Poor / q Deceased / ______
Brother #2 / q Excellent / q Good / q Fair / q Poor / q Deceased / ______
Sister #1 / q Excellent / q Good / q Fair / q Poor / q Deceased / ______
Sister #2 / q Excellent / q Good / q Fair / q Poor / q Deceased / ______

MEDICAL CONDITIONS & ILLNESSES

Have you ever had or do you now have any of the following medical conditions, illnesses or diseases?

Please check YES or NO for EACH item.

YES / NO / YES / NO / YES / NO
9. / q / q / Polio / 26. / q / q / Recurrent sinusitis / 43. / q / q / Hernia or rupture
10. / q / q / Diphtheria / 27. / q / q / Hearing loss/ear disease / 44. / q / q / Ulcers
11. / q / q / Rheumatic fever / 28. / q / q / Rheumatic heart disease / 45. / q / q / Testicular masses
12. / q / q / Hepatitis / 29. / q / q / Heart murmur/problems / 46. / q / q / Hemorrhoids
13. / q / q / Tuberculosis / 30. / q / q / Pericarditis / 47. / q / q / Bleeding disease
14. / q / q / Collapsed lung / 31. / q / q / High blood pressure / 48. / q / q / Anemia
15. / q / q / Pneumonia / 32. / q / q / Elevated cholesterol / 49. / q / q / Phlebitis
16. / q / q / Pleurisy / 33. / q / q / Arthritis/joint problems / 50. / q / q / Asthma/hay fever
17. / q / q / Diabetes / 34. / q / q / Bone infection / 51. / q / q / Skin disease/rash
18. / q / q / Allergies / 35. / q / q / Chondromalacia / 52. / q / q / Measles
19. / q / q / Tumors/Cancer / 36. / q / q / Seizures/Epilepsy / 53. / q / q / Mumps
20. / q / q / Muscular disease / 37. / q / q / Migraine headaches / 54. / q / q / Mononucleosis
21. / q / q / Eye disease / 38. / q / q / Neurological disorder / 55. / q / q / Malaria
22. / q / q / Color blindness / 39. / q / q / Goiter/thyroid disease / 56. / q / q / Car or air sickness
23. / q / q / Near sightedness / 40. / q / q / Enlarged organs (spleen) / 57. / q / q / Nervous breakdown
24. / q / q / Far sightedness / 41. / q / q / Kidney or bladder disease / 58. / q / q / Mental disorder
25. / q / q / Nasal polyps / 42. / q / q / Gastrointestinal bleeding / 59. / q / q / Eating disorder

Student Name ______Page 2 of 6

(Last) (First) (Mid. Initial)

INJURIES & SYMPTOMS

Do currently have or have you ever had any of the following symptoms, problems or injuries?

Please check YES or NO for EACH item.