The University of the South Is Hipaa Compliant

Sewanee

University of the South

INSURANCE FORM

THE UNIVERSITY OF THE SOUTH IS HIPAA COMPLIANT

(Information regarding HIPAA can be found at )

Student’s Name: ______Nickname: ______Gender: ______

Date of Birth: ______SSN: ______Student’sCell Phone Number: ______

Mailing Address: ______City: ______State/Zip: ______

Parents’,Guardian,Spouse’sName:______

Home Phone: ______Mother’s Cell Phone: ______Father’s Cell Phone: ______

EMERGENCY CONTACT: ______Relationship(Mandatory):______

Home Phone: ______Cell: ______Work: ______

INSURANCE

All students are required to have adequate health insurance that will provide coverage while in the Sewanee area. It is the responsibility of the student and/or parent to ensure that there are no restrictions or limitations with your insurance coverage should medical care be necessary.

PLEASE BE ADVISED THAT HMO, MANAGED CARE PLANS, KAISER, AND STATE MEDICAID PLANS MAY NOT PROVIDE COVERAGE IN THE SEWANEE AREA.

**** A CLEAR COPY OF BOTH THE FRONT AND BACK OF THE INSURANCE CARD MUST BE SUBMITTED WITH FORMS ****

HEALTH INSURANCE:______

NAME & ADDRESS OF INSURANCE COMPANY TELEPHONE

______

Name of Policy HolderPolicy Holders DOB & SSN Employer

______

Policy ID/Certificate Number Group Number HMO PPO

(Required Information)

PERMISSION FOR DIAGNOSTIC AND TREATMENT PROCEDURES

I hereby authorize the medical staff of the University of the South, their agents or consultants, to perform diagnostic and treatment procedures, which in their judgment may become necessary while the student is enrolled at the University of the South. I understand that Athletic Training Room and Wellness Center professionals will have access to patient records, as deemed necessary, to facilitate and implement effective treatment.

Student Signature: ______Date (mm/dd/yr):______

Parent/Guardian Signature: ______Date (mm/dd/yr): ______

(A parent or legal guardian must sign if the student-athlete is under age 18)

Student’sName:______

Varsity/ClubSportParticipatingIn: ______

Year inSchool: ______

Today’sDate:______

** THIS PAGE TO BE COMPLETED BY STUDENT. PLEASE TAKE THIS WITH YOU WHEN COMPLETING YOUR PHYSICAL WITH YOUR PHYSICIAN **

Owner’s Certification Concerning Use of Private Vehicles on University Business

In consideration of the use of my private vehicle to transport fellow students and/or other participating members from club sports events, I hereby certify that I presently have a policy of insurance providing a MINIMUM COVERAGE of $15,000 each person/ $30,000 each occurrence bodily injury, plus $5,000 property damage, if split limit, or coverage of $35,000 if single limit. I also certify that I am insured through:

______

Insurance providerPolicy numberContact info

______

Car OwnerOwner SignatureDate

The Athletic Department will reimburse me for the use of my private vehicle by direct reimbursement for gas if deemed budgetary acceptable and prior approval has been gained upon presentation of receipts.

Club Sport Injury/Accident Report

Type of Activity (please circle)

Intramural Club Sport

Date of incident:______Time: ______a.m. p.m.

Location of incident (please circle)

Intramural field | Fowler Center | Practice (football) field | Kyle Rote Jr. field | Other______

Describe other:______

Gender (please circle) M F Age:______

Person injured:______Student ID #______

Email address of injured:______Phone #______

Nature of accident and first aid administered: (attach additional sheet if needed)

______

Description of accident: How did it occur? What was the person doing? List any unsafe conditions at the time of the accident. (Attach additional sheet if needed.)

______

Witness # 1Name: ______Witness # 1 Phone # ______

Witness #2 Name: ______Witness # 2 Phone # ______

Signed:______

Athletic department representative Person reporting

COMPLETE AND FILE WITH THE Athletic Department

IMMEDIATELY AFTER INCIDENT HAS OCCURRED

Sewanee tigers
Office of Athletic Communication  735 University Ave.  Sewanee, Tenn. 37383 Phone 931.598.1136  Fax 931.598.1673

Club Sport Roster

No.Name (if available)Pos.Cl.Hometown/High School

Coaches:

Head coach:

Assistants:

Sewanee tigers
Office of Athletic Communication  735 University Ave.  Sewanee, Tenn. 37383

Phone 931.598.1136  Fax 931.598.1673

Club Sport Schedule

DateOpponentLocationTime

_____

Coaches:

Head coach:

Assistants:

Sewanee tigers
Office of Club Sports 735 University Ave.  Sewanee, Tenn. 37383

Phone 931.598.1901  Fax 931.598.1673

Club Sport Travel Form

To be filed with the Director of Club Sports a minimum of48 hours prior to departure.

Team Traveling: ______

Departure date: ______Time: ______

Return date: ______Time: ______

Destination: ______

Transportation: ____ Sewanee vans/mini bus ____ Charter bus

____ Other (specify) ______

Hotel: ______

(if applicable)NamePhone

Travel roster for trip:

Coaches: ______

______

Students (student-athletes, managers, etc)

______

______

______

______

______

______

______

Sewanee tigers
Office of Club Sports 735 University Ave.  Sewanee, Tenn. 37383

Phone 931.598.1901  Fax 931.598.1673

Equipment Inventory

Item # in stock 5/1/16 # issued 9/1/16 # returned 5/1/17

Coaches:

Head coach:

Assistants:

Sewanee tigers
Office of Athletic Communication  735 University Ave.  Sewanee, Tenn. 37383

Phone 931.598.1136  Fax 931.598.1673

Competition Results

Club sport ______

Sewanee Opponent Date

______

Coaches:

Head coach:

Assistants:

Sewanee tigers
Office of Club Sports 735 University Ave.  Sewanee, Tenn. 37383

Phone 931.598.1901  Fax 931.598.1673

Club Sport CrewSwim Evaluation

Each Crew member shall passa basicswim qualification, conducted by the Crew coach demonstrating the following:

a. Tread water for 30 seconds.

b. Swim one entire length of the pool(25 meters),utilizing anystroke or combination

of strokes.

c. Demonstrate the usage of a self- made floatation device; clothing, floating debris etc.

d. If they cannot pass a certified floatationdevice will be provided.

Date of test: ______

Student name: ______

Coach evaluator: ______

Pass: ______Yes _____ No

REQUEST FOR PAYMENT

Date
Payee: (legal name)
Banner ID:
Address:
Date Required
Special Handling
Mail out: (preferred)
SPO:
Hold for Pickup: / Name/Extension
(Normal processing time is seven days after receipt by Accounts Payable)
DESCRIPTION/PURPOSE OF PAYMENT / INDEX / ACCOUNT / AMOUNT
TOTAL / $
INSTRUCTIONS: Use only to initiate payment of advances (indicate destination and dates of trip), honoraria and awards (Social Security number required for these payment types), refunds, petty cash reimbursement (attach receipts), and similar transactions where an invoice or other document is not available. If invoice is available, this form is not required.
REQUESTED BY: / DATE
APPROVED BY: (if disbursement is to the requestor above) / DATE
CASH RECEIVED: / DATE

Sewanee Club Sports Handbook (2017-2018)Page 1 of 10