Proof of Insurance

WPI Athletic Training:

Proof of Insurance

Acceptance of Risk and Consent to Treatment

Today’s Date:______

Name:______Date of Birth: ______Year of Graduation:______

School Address:______Sport:______

Home Address: ______Cell Phone: ______

Emergency Contact: ______Emergency Contact Number:______

Proof of Insurance

Policy Holder:______Relation to Student-Athlete:______

Did you purchase WPI School Insurance (circle one): YES NO (If yes, no need for copy of card.)

Copy of Insurance Card:

FRONTBACK

Acceptance of Risk and Consent for Treatment

Acceptance of Risk:WPI, in compliance with NCAA guidelines, reminds its student athletes of the inherent risk of injury during intercollegiate athletic participation. WPI and its athletic administrators, coaches, and sports medicine staff share the management of these risks by endeavoring to create a safe environment for competition. For their part, student athletes are strongly advised to adhere to their coaches’, athletic trainers’, and associated physicians’ health and safety instructions (e.g. WPI Concussion Management Plan), including the rules of their sport, while participating in contests, practices, training sessions, and related travel to effectively reduce the risks of injury.

Consent for treatment: I give permission to WPI team physicians and/or consulting physicians as well as the Athletic Training staff to render any treatment that may be necessary regarding my health and well-being. I authorize the medical staff to render the necessary medical services. I understand that this may include treatment such as medical or surgical care that may need to be provided by the caring team physician or consulting physician. Also, by permitting necessary treatment, I realize that I authorize the athletic trainers to render any treatment that may fall under the headings of preventative first-aid, rehabilitation, and emergency treatment. During these instances, the athletic trainer will be working under the supervision of the WPI team physicians, consulting physicians, and/or health services. I also realize that by giving consent for proper care, I give permission for hospitalization when necessary at an accredited hospital. The Athletic Training Staff maydiscuss any injuries or health concerns with coaches and health care providers, including health services, counseling center and office of disability services.

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Student Signature Parent or Guardian Signature (If Minor)Parent or Guardian Printed Name

Worcester Polytechnic Institute – 100 Institute Rd. – Worcester, MA 01609-2280

508.831.5733 (office) – 508.831.6185 (fax)