Below are all the forms that will be required of each returning student–athlete for the 2012-2013 school year.  These forms must be completed and returned to the Sports Medicine Department prior to the pre-participation physical examination.  The appropriate deadline for each sport is listed below.  Failure to complete any or all forms by the deadlines will disqualify you from having a pre-participation physical, and thus exclude you from participation in athletic department sponsored practices and competitions.  There will be no exceptions to this policy.  If you have questions regarding these forms, you should contact the Sports Medicine Department at either 814-898-6340 or 814-898-7227.

Please pay close attention to the following directions.  Several of our forms have had slight modifications as compared to last year’s forms.  Do not assume all information being requested is the same as last year!

Please use the following as a checklist to complete these forms:

• Please read these forms carefully. Each of these 2 files must be completed and on record with the Sports Medicine Department (addresses listed below), prior to the appropriate deadline, in order for you to have a pre-participation physical examination.

• All signatures requested must be correct and included in order for the insurance packet to be deemed complete.  

• Handwritten Copies of these packets are unacceptable and thus deemed incomplete.

 

• Save each of the following files to your hard drive and then fill each file out completely and save it again to your hard drive.

 

• Print a hard copy of File # 1 Athlete Insurance / Insurance Claim Filing / Medical Addendum Forms File (a total of 6 pages).

 

• Print a hard copy of File # 2 HIPAA / Assumption of Risk / Info Release Forms / General Policies & Procedures Statement / Training Room Policies / General Policies Forms File , PAGE 9 ONLY.

 

• Make sure the correct signatures are included on pages 3, and 6 of file # 1 and Page 9 of File # 2.  The signature on page 3 of file # 1 must be the insurance policy holder’s signature.

 

• Email Saved File # 1 to either Jeff Webster ATC jxw63@psu.edu or Angela Meserole ATC amm43@psu.edu

 

• Mail Hard copy of File # 1 and Page 9 of File # 2 to the address listed below (a total of 7 pages).  Please include a copy of your most recent insurance cards.

 

Penn State Behrend Sports Medicine 

5103 Station Road

Junker Center

Erie, PA 16563-0400

 

• DO NOT STAPLE the Hard Copy (Paper) Forms

We realize the depth of the information we are asking you to complete.  However, due to more stringent medical privacy acts and our need for more detailed medical histories for our records, as well as those of our insurance carrier, we need to constantly update and expand our base of medical records for all Penn State Behrend student-athletes.  We are asking for your cooperation and patience as we continue to implement these procedures.  Please be aware that all of this information will continue to be confidential, and will only be used as it pertains to your need for medical treatment and referral.

2012-2013 Deadlines

• Friday August 3, 2012---All Sports Paperwork (recruited) Due for the following teams: M&W Soccer, M&W Tennis, Volleyball, M&W Cross Country, M&W Water Polo, M&W Golf, Baseball, Softball, M&W Basketball, M&W Swimming and M&W Track and Field (Indoor and Outdoor)
  
  

• All Walk-ons (not recruited) Paperwork Due by August 13, 2012 for (MWGOLF, MWSOC, MWXC, MWP, WTEN & VB)
  
  

• All Spring (non-traditional) Walk-ons (not recruited) Paperwork Due by August 27, 2012 for (BASE, SB & MTEN)
  
  

• All Winter & Spring Walk-ons (not recruited) Paperwork Due by September 10, 2012 for (SWIM, MWBB, MWTF & WWP)
  
  

• All 2^nd Semester Transfers and Spring SOC/VB Walk-ons (not recruited) Paperwork Due By January 7, 2013