Do you have medical insurance?
If you have insurance:
I verify that all the information above is current and correct. I authorize Cal Poly State University to notify my parents/guardians in case of an emergency.
If you don't have insurance:
In exchange for participation in Cal Poly's Club Sports Program, I accept all financial responsibility for any and all medical expenses that I may incur as a result of participation in the program. Further, in exchange for participation in the Cal Poly Club Sports Program, for myself, and for my heirs, executors, legal representative, successors and assign, I hereby waive all claims and/or courses of action, including negligence, against the State of California, the Trustees of the California State University, California Polytechnic State University and all of their officers, directors, employees and agents, arising out of, or in any way connected with, my participation in the aforementioned program. 'Participation' includes, but is not limited to, travel to and from the activity. I verify that the information above is current and correct.
Club Sport Concussion Protocol ~ Agreement Form
California Polytechnic State University Club Sports program is concerned about the well-being of all club sport participants. To ensure a safe and healthy athletic experience please complete the following.
By checking the box next to each statement below, I acknowledge that I have read each provision and agree to comply in regards my participation in Distance club for the 2016-17 Academic Year.
I shall familiarize myself with the NCAA Concussion Fact Sheet for Student-Athletes
I shall be Impact baseline tested prior to participation in any club sport. After reviewing this concussion protocol, complete the Mandatory Baseline Test
I am aware that a concussion can affect my ability to perform everyday activities, and affect reaction time, balance, sleep, and classroom performance.
It is my responsibility to report to a health professional if I receive a blow to the head or body and experience signs, symptoms or behaviors of a concussion as identified on the Concussion Fact Sheet for Student-Athletes. I will follow up at Health Services as appropriate.
I may notice some symptoms of a concussion immediately, but other symptoms may show up hours or days after the initial injury. It is my responsibility to report any delayed signs or symptoms to a health care professional or Health Services.
If I suspect a teammate has a concussion, I am responsible for reporting the injury to Health Services.
Following a concussion, the brain needs time to heal. I am more likely to have a repeat concussion if I return to play before my symptoms resolve. In rare cases, repeat concussions can cause permanent brain injury or death. Because of this, I understand it is important to accurately report my signs and/or symptoms if I have been diagnosed with a concussion.
Long term risks and consequences of concussion are not readily known. Physical and cognitive rest is required to recover from a concussion. In the event of a concussion I will discuss with my professors any accommodations needed to meet academic requirements.
Recommendations for returning to play will be made by a health professional. I understand that the Director of the Club Sports program will consider the evaluations of the health professional and may request additional evaluations prior to allowing the club sport participant to return to play.