2016 spring tryouts information packet

UNCG CHEERLEADING
2016 SPRING TRYOUTS
INFORMATION PACKET
“We discover and develop champions in life.” -The Spartan Way
2016 UNCG Cheerleading
Spring Tryouts
Spring tryouts will be held Friday, April 8th &
Saturday, April 9th Tryout Fee: $20/person
Times and locations are as follows:
Friday, April 8, 2016
Time: 5:30 pm - 10 pm
Location: Research Gym, Coleman Building 2nd floor
Please arrive by 5:15pm
Saturday, April 9, 2016
Time: 8 am - Noon
Location: Research Gym, Coleman Building 2nd floor
The Research Gym is located on the second floor of the Coleman Building.
Participants may park in the Walker Avenue Parking Deck at a rate of $1/
hour.
All Tryout Sessions for the UNCG Cheerleading squad are closed,
without exception.
Video Tryout Submission
Submission of a tryout video will be accepted. However, situations will be handled on a
case-by-case basis and the coaching staff reserves the right to deny the option of a video tryout
at their discretion.
All questions regarding UNCG Cheerleading tryouts may be directed in
writing to the Head Coach, Dee Brennan, [email protected] or
[email protected].
“We discover and develop champions in life.” -The Spartan Way
General Tryout Information
All tryout participants must be:
 Current, full-time UNCG students (enrolled in a minimum of 12 credit hours)
 College transfers, or incoming freshman with an acceptance letter.
 All tryout participants must have a minimum of a 2.3 semester GPA at the time of tryouts.
Tryout Attire

You must present a “clean cut” image to be selected as a UNCG Cheerleader. Body piercings,
tattoos, extreme hairstyles/color are not acceptable at tryouts or in uniform if selected as a
team member. Remove all piercings and cover all tattoos prior to arrival at tryouts.
Expected attire for tryouts is as follows:
Ladies:
 bright colored logo-free bra top
 black shorts
 Hair bow and game ready make-up
 Cheer shoes
**You should dress in form fitting athletic clothing. Bra tops, fitted tanks/tees are all
acceptable.
Gentlemen:
 White or light colored logo-free t-shirt
 black colored gym shorts
 Cheer shoes
“We discover and develop champions in life.” -The Spartan Way
General Tryout Information continued
Tryout Paperwork Requirements
All tryout participants must submit the following paperwork and bring $20tryout fee (checks
made payable to UNCG Athletics) no later than Monday, April 4th NO EXCEPTIONS! The
Tryout Application and the paperwork included in the UNCG Cheerleading Tryout Packet
must be submitted directly to the UNCG Cheerleading Staff Advisor using one of the methods
listed below. All tryout participants are encouraged to submit all paperwork as soon as
possi-ble so any issues that may arise can be addressed prior to the final deadline..
By Mail:
By Fax:
By Drop-off:
UNCG Athletics
To: Dacia Ijames
Room 101C, HHP Building
c/o Dacia Ijames
Re: UNCG Cheer
Attn: Dacia Ijames
1408 Walker Ave, 101C HHP
Tryouts
Greensboro, NC 27402-6168
Fax Number: 336.334.4063
CHECKLIST OF REQUIREMENTS:
 Tryout Registration Fee: $20, check made payable to UNCG Athletics
 UNCG Cheerleading Tryout Application (Appendix A)
 All questions on the application must be completed before the application will be processed.
 Headshot (both listed below)
 Please submit a photo headshot of yourself and submit along with the other required paperwork.—AND—
 Photo copy of UNCG Student ID, if you are a current student
 Proof of full-time enrollment at UNCG
 Documentation must be provided via a print-out from UNCGenie that must contain participant’s name and current GPA (Appendix B)
 Copy of 2015 Fall Class Schedule (Appendix C)
 Students are considered full-time only if they are enrolled in a minimum of 12 credit hours
 Acceptance letter to UNCG, if an incoming freshman or transfer student
 Copy of current physical (conducted within the past 6 months) (Appendix D)
**(Must be signed by a physician)
 Health Insurance Information Form (Appendix E)
 A copy of the front and back of the participants insurance card must accompany this form
 Consent to Disclose Protected Health Information Form (Appendix F)
 This form will only be kept on file should the participant be selected as a member of the squad
 This form requires the signature of a parent or legal guardian, regardless of participant’s
age
 ICA Agreement & Release Form (Indemnity Form) (Appendix G)
 Participants must have a parent or legal guardian’s signature
 This form requires the signature of a parent or legal guardian, regardless of participant’s
age
 Insurance Information & Injury Release Forms (Appendix H & I)
 Appendix H requires the signature of a parent or legal guardian, regardless of participant’s age. Appendix I only requires a signature of a parent or legal guardian if participant is less than 18 years of age.
 Sickle Cell Screening Results (Appendix J) **Returning members DO NOT have to complete this
requirement. Prospective new members only!
 Lab Results AND Appendix J must be submitted before tryouts. No exceptions.
 Please give 24 to 48 hours to receive your lab results.
 Appendix J requires the signature of a parent or legal guardian, regardless of participant’s
age.
“We discover and develop champions in life.” -The Spartan Way
General Tryout Information continued
Skill Requirements
Stunt Requirements:
 Two to three stunts or stunt sequences and a 360 dismount with tryout participants determined by the coaching staff
 One stunt or stunt sequence, of your choice, with other tryout participants including a minimum of one transition
Jumps & Tumbling Requirements: **ALL UNCG CHEERLEADERS MUST TUMBLE!
 Toe touch
 Toe-Handspring and/or Toe-Tuck
 Demonstrate a minimum of 1 standing tumbling skill (Standing back handspring
or higher)
 Demonstrate a minimum of 1 consecutive running tumbling pass (RBHS series or
higher)
**Any additional material taught during the tryout process**
**It is important that you attend both days of the tryout process. All tryout material will be
taught on Thursday of the tryouts.
Scores will NOT be released. The coaching staff will make all final decisions on team member selection. Any candidate that has questions after the team selections are announced
may e-mail the UNCG Cheerleading Coach at [email protected] OR
[email protected] any time AFTER the weekend. Outbursts or questions from parents
will not be accepted.
If you have ANY questions regarding paperwork or the general audition process, please contact the staff advisor in advance! Being proactive will insure you are prepared and cleared
to participate in auditions.
We are looking for well-rounded cheerleaders with outstanding skills and
CHEER-LEADING ability!
We realize that not all “stunters” have advanced tumbling skills and vice versa. Be prepared
to take direction and learn during the tryout process. Do not assume that a weakness or
lack of skill in any one area will automatically disqualify you as a team member. Display an
eager and positive attitude at all times.
Keep working on your skills! We look forward to meeting and working with you!
GO SPARTANS!
“We discover and develop champions in life.” -The Spartan Way
UNCG
UNCGCheerleading
Dance Team Q&A
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Do you offer any partial or full scholarships for cheerleaders?
No scholarships are currently provided to UNCG Cheerleaders.
Does UNCG have a coed team or all-girl?
Currently UNCG’s Cheerleading squad consists of females only, but tryouts are
open to both males and females.
What is the UNCG Cheerleading squad size?
Our maximum squad size is 20 cheerleaders and we may have alternates.
When are tryouts?
The UNCG Cheerleading Squad holds one tryout in mid April. If needed, a Fall
tryout will take place but will not always occur.
What are the additional benefits of being a UNCG Cheerleader?
The UNCG Cheerleading squad is sponsored by the UNCG Athletic Department.
Team members are able to pre-register for classes, have access to the Athletic
Training room and staff, study hall sessions, strength and conditioning coaches,
uniforms, shoes, travel accommodations and meal stipend when traveling and
tickets to UNCG’s home athletic events.
Does your team compete?
Currently, the UNCG Cheerleading squad does not compete on a regular basis.
However, we have attended the NCA/NDA Collegiate National Competition in
the past and plan to do so this year.
Does your team attend summer camp?
Yes, the UNCG Cheerleading squad attends a summer camp.
Does UNCG have a dance team?
Yes, the UNCG Spartan G’s Dance Team, is a part of the UNCG Spartan Spirit
Program along with the UNCG Cheerleading Squad, UNCG Band of Sparta &
Spartan Mascot, Spiro.
Does UNCG uphold the rules and regulations set forth by the American Association
of Cheerleading Coaches and Administrators (AACCA)?
Yes, the UNCG Cheerleading squad abides by all rules and regulations set forth
by AACCA. For more information on these rules and regulations visit
www.aacca.com.
“We discover and develop champions in life.” -The Spartan Way
UNCG CHEERLEADING SQUAD AUDITION APPLICATION
GENERAL INFORMATION
NAME: _________________________________________
(First, Middle, Last)
UNCG STUDENT ID #: __________________
AGE: ________
DATE OF BIRTH: __________________
(mm/dd/yy)
CLASS RANK FOR THE 2016-17 ACADEMIC YEAR (circle one):
FRESHMAN
SOPHOMORE
JUNIOR
SENIOR
OTHER
UNCG E-MAIL ADDRESS: _________________________________________
ALTERNATIVE E-MAIL ADDRESS: _________________________________________
PERMANENT ADDRESS (PARENT’S ADDRESS): ______________________________________________________
(Street Address)
____________________________
________
__________________
(City)
(State)
(Zip Code)
CELL PHONE #: _______________________
HOME PHONE #: _______________________
MAJOR: _________________________________________ EXPECTED DATE OF GRADUATION: _____________
MOTHER’S NAME: _________________________________________ CELL PHONE #: _____________________
FATHER’S NAME: _________________________________________ CELL PHONE #: _____________________
ADDITIONAL INFORMATION
DO YOU HAVE ANY CONFLICTS WITH THE TIME COMMITMENT AND EXPECTATIONS DURING THE SUMMER OR
UPCOMING SEASON? (I.E. WEDDINGS, TRAVEL, STUDYING ABROAD, WORK COMMITMENTS) _____________
IF YES, PLEASE EXPLAIN: ________________________________________________________________________
____________________________________________________________________________________________
DO YOU HAVE ANY SPECIFIC HEALTH CONDITIONS OR LIMITATIONS WE SHOULD BE AWARE OF? ____________
IF YES, PLEASE EXPLAIN: ________________________________________________________________________
____________________________________________________________________________________________
HAVE YOU BEEN UNDER THE CARE OF A PHYSICIAN WITHIN THE PAST YEAR? _____________________________
IF YES, PLEASE EXPLAIN: ________________________________________________________________________
____________________________________________________________________________________________
Page 1
UNCG CHEERLEADING SQUAD AUDITION APPLICATION
CHEERLEADING BACKGROUND INFORMATION
HOW MANY YEARS HAVE YOU BEEN CHEERING? _________________________________________
PLEASE LIST THE NAMES OF TEAMS, GYMS, ETC. YOU HAVE CHEERED WITH IN THE PAST AND HOW MANY
YEARS YOU WERE WITH THAT ORGANIZATION:
TEAM/GYM NAME
YEARS WITH ORGANIZATION
1.
_________________________________________
___________________
2.
_________________________________________
___________________
3.
_________________________________________
___________________
WHICH STUNT POSITION WILL YOU BE AUDITIONING FOR? (check all that apply)
 FLYER
MAIN BASE
SECONDARY BASE
BACK SPOT
WHICH STANDING TUMBLING SKILLS DO YOU CURRENTLY HAVE MASTERED? (check all that apply)
BACK HANDSPRING
BACK TUCK
TOE HANDSPRING
TOE TUCK
OTHER (please specify) __________________________________________________
WHICH RUNNING TUMBLING SKILLS DO YOU CURRENTLY HAVE MASTERED? (check all that apply)
BACK HANDSPRING SERIES
FULL
BACK TUCK
LAYOUT LAYOUT STEP OUT
OTHER (please specify) __________________________________________________
PLEASE LIST ANY ACCOMPLISHMENTS YOU HAVE EARNED THAT YOU WOULD LIKE US TO BE AWARE OF:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
LADIES UNIFORM INFORMATION
UNIFORM TOP SIZE:
 XS (30-32)
UNIFORM SKIRT SIZE:  SMALL
CHEER SHOE SIZE:
TENNIS SHOE SIZE:

S (32-34)
M (34-36)
L (36-38)
MEDIUM
MEDIUM LONG
LARGE

7

9
5.5

7.5

9.5
6

8

10
6.5

8.5


7

9
5.5

7.5

9.5
6

8

10
6.5

8.5
5
5
T-SHIRT SIZE:
 X-SMALL
 SMALL
MEDIUM
LARGE
SWEATSHIRT SIZE:
 X-SMALL
 SMALL
MEDIUM
LARGE
SWEAT PANT SIZE:
 X-SMALL
 SMALL
MEDIUM
LARGE
WARM-UP JACKET SIZE:
 X-SMALL
 SMALL
MEDIUM
LARGE
WARM-UP PANT SIZE:
 X-SMALL
 SMALL
MEDIUM
LARGE
M (34-36)
L (36-38)
SPORTS BRA SIZE:
 XS (30-32)
S (32-34)
Page 2
UNCG CHEERLEADING SQUAD AUDITION APPLICATION
MEN’S UNIFORM INFORMATION
 SMALL
MEDIUM
LARGE
X-LARGE
UNIFORM PANT SIZE:  SMALL
MEDIUM
LARGE
X-LARGE
UNIFORM TOP SIZE:

7

9
5.5

7.5

9.5
6

8

10
6.5

8.5

11


7

9
5.5

7.5

9.5
6

8

10
6.5

8.5

11
T-SHIRT SIZE:
 SMALL
MEDIUM
LARGE
X-LARGE
SWEATSHIRT SIZE:
 SMALL
MEDIUM
LARGE
X-LARGE
SWEAT PANT SIZE:
 SMALL
MEDIUM
LARGE
X-LARGE
CHEER SHOE SIZE:
TENNIS SHOE SIZE:

5
5
WARM-UP JACKET SIZE:
 SMALL
MEDIUM
LARGE
X-LARGE
WARM-UP PANT SIZE:
 SMALL
MEDIUM
LARGE
X-LARGE
Page 3
Appendix B
Sample print-out from UNCGenie:
Your Name Here
Appendix B
Sample print-out from UNCGenie:
UNCG CHEER AND DANCE PHYSICAL
Name: _________________________________________ Date: _____________
Sport: CHEER / DANCE
School Address: _______________________________________________________________________________
University ID: _______________
DOB: __________
Telephone Number: _______________________
Parents’ Name: _______________________________________________________________________________
Parents’ Address: ______________________________________________________________________________

List any allergies (including latex):___________________________

Medications currently taking (including birth control): __________________________________________
______________________________________________________________________________________
Last Tetanus: __________________
*Please answer the questions below. Fill in details of “yes” answers in space provided.*
1.
Have you ever been hospitalized?
Yes
No
2.
Have you ever had surgery?
Yes
No
3.
Have you ever passed out during exercise?
Yes
No
4.
Have you ever been dizzy during exercise?
Yes
No
5.
Have you ever had chest pain during exercise?
Yes
No
6.
Have you ever had a head injury, seizure or unconscious?
Yes
No
7.
Have you ever had heart trouble, or high blood pressure?
Yes
No
8.
Has anyone in your family died suddenly before the age of 50 of heart problems?
Yes
No
9.
Have you ever had a heat related illness?(cramps, dizzy or passed out)
Yes
No
10.
Do you have any other medical problems?(ie asthma, diabetes, hepatitis,
Impaired function of any organ)
Yes
No
11.
Do you have any menstrual irregularities or problems?
Yes
No
12.
Do you wear glasses, contacts, braces of any kind, orthotics, hearing aid?
Yes
No
13.
Have you ever injured (sprained, dislocated, fractured etc)? Circle all that apply.
Neck
Chest
Hip
Thigh
Knee
Ankle
Foot
Toes
Lower Leg
Elbow
Arm
Wrist
Back
Head
Fingers
Shoulder
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Page 2
EXAMINATION
Height __________
Weight __________
RHR __________
Heart ____________________
Lungs ____________________
Abdomen __________
General __________
BP __________
Other __________
MUSCULOSKELETAL
Neck __________
Back __________
Shoulder __________ Knee __________
Elbow __________
Ankle __________
Wrist __________
Hip __________
Hand __________
Foot __________
ASSESMENT
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
RECOMMENDATION
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
__________________________________________
CLEARANCE
No Restrictions ____________________
Deferred Until ____________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________
Name of Provider
_____________________________________
Signature of Provider
__________________
Date
Appendix E
Health Insurance Information for 2016-17 Academic Year
Athlete’s Name__________________________________________________________
Last
First
MI
Date of Birth
/
/
Athlete’s Home Address___________________________________________________________________
___________________________________________________________________
City
State
Zip Code
Athlete’s University ID #
Athlete’s SS#________________________
Sport _______________________________
Complete Name of Insurance Company
______________________________________________________
Address to Mail Claim
______________________________________________________
______________________________________________________
______________________________________________________
Policy Holder’s Name_________________________________________________________
Last
First
MI
Policy Holder’s Address
__________________________________________________________________________
Number
Street
__________________________________________________________________________
City
State
Zip Code
Policy Holder’s SS#
-
-
Policy Holder’s DOB
Please copy the front and back of your insurance card and affix it below.
(Front)
(Back)
/
/
Appendix F
Consent to Disclose Protected Health Information









I hereby consent to allow the UNCG Athletic Training Staff to disclose Protected Health Information
concerning any injury or athletically related illness to my coaching staff and the UNCG Athletics
Administration.
I hereby consent to allow UNCG Athletic Department Personnel to disclose Protected Health Information
concerning any injury or athletically related illness to my parents, legal guardians, or wards.
I authorize payment of medical benefits to all providers of services for all services and materials they
provide during the care of any injury/illness.
I agree to supply any and all information requested by my primary insurance, UNCG and the excess
insurance company, and the NCAA and their excess insurance company in a timely manner in order to
expedite the claim process.
I hereby authorize UNCG and their excess insurance company to secure and inspect copies of case history
records, lab reports, diagnoses, x-rays, and other data pertaining to the injury/illness I am receiving care for
or previous confinements, if disabilities relevant, to the care of the injury/illness.
I authorize the UNCG Athletic Training staff and/or my coach to hospitalize and secure treatment for me
for any athletic injury/illness. If the athlete is under 18 years of age, the undersigned parent/guardian grants
permission the UNCG Athletic Training staff and/or the coach to hospitalize and secure treatment for their
son/daughter/ward for any athletic injury/illness.
This consent is irrevocable for the duration of any executed disclosure due to an athletically related illness
or injury.
A photo static copy of this consent shall be deemed as effective and valid as the original.
I will notify the UNCG Athletic Training staff immediately upon any change in the above health insurance
information.
_____________________________________________________
Athlete’s Signature
______________
Date
_____________________________________________________
Parent/Guardian Signature
______________
Date
Parent/Guardian’s Name
_________________________
Relationship______________________
Home Phone _________________________
Work Phone______________________
Parent/Guardian’s Name
_________________________
Relationship______________________
Home Phone _________________________
Work Phone______________________
Alternate Person to Contact in Case of Emergency __________________________________
Relationship __________________________________
Home Phone __________________________________
Work Phone __________________________________
Appendix G
UNCG Athletics
Waiver, Release of Liability, & Indemnity Agreement
I am aware and understand that any physical activity, including (but not limited to) soccer, basketball, volleyball, tennis,
baseball, softball, cheerleading, weight lifting and conditioning, can be a dangerous activity, which may result in serious
personal injury. These injuries include, but are not limited to, serious neck and spinal injuries, complete or partial paralysis, brain damage, serious injuries to bones, joints, ligaments, and tendons; serious injury to other areas of the
body, general health and well-being, and even DEATH.
In consideration of the University of North Carolina Greensboro (UNCG) permitting me to use its Athletic Facilities, I
agree to the following:
I will obey all rules established by UNCG Athletics for the use of its facilities.
I will obey any and all instructions or directions given to me by UNCG Athletic personnel concerning the use of its facilities.
I assume all financial responsibility for any injury or damage as a result of my use of UNCG Athletic Facilities.
To the fullest extent allowed by law, I hereby release and agree to hold harmless UNCG, its trustees, officers, agents,
employees, coaches, professors, students, athletic trainers and other medical personnel from any and all liability
arising out of any injuries to my person or property, or losses of any kind or nature whatsoever, which may result
from, or which arise in connection with, my use of the UNCG Athletic Facilities, even to the extent that such injuries
may arise from the negligence of those listed above.
To the fullest extent allowed by law, I will indemnify and hold harmless, including attorney’s fees and court costs, those
listed above for any injury to person or property that I may cause others in the course of my use of the UNCG Athletics Facilities or due to my failure to obey any rules, directions, or instructions.
I acknowledge that I have read this agreement fully and that I understand the legal rights I waive by signing this agreement. I further acknowledge that I am aware of the potential hazards incident to engaging in physical activity.
_________________________________
Signature of Participant
Date
___________________________________
Signature of UNCG Representative
Date
_________________________________
Printed Name of Participant
___________________________________
Printed Name of UNCG Representative
______________________________________
Printed Name of Parent/Guardian
Date
__________________________________________
Signature of Parent/Guardian
Insurance Information
2016-2017
UNCG currently requires all students to have primary medical insurance. It is the responsibility of each student to prove that
he/she has medical insurance, and if not, the student account will be automatically billed per semester. The premium has not
been finalized for the 2016-17 year but will be announced this summer. We strongly recommend that you research and
understand your insurance benefits prior to your arrival on campus. If the benefits are insufficient or non-existent in
NC(HMO), you may wish to call your carrier to inquire about alternatives. Another option would be to choose/default to the
school policy. Should the status of your insurance coverage change during the course of the school year, please be sure to
communicate this with the athletic training staff immediately. The UNCG Department of Intercollegiate Athletics carries an
excess insurance policy for each student-athlete to cover athletic related injuries. This policy carries a $0 deductible, per
injury.
When a student-athlete is injured during athletic participation, all medical insurance claims will be filed with your personal insurance company. Once your primary insurance company pays their portion of your bill, our excess policy will cover the
remain-ing balance. In order to help process payments you may be required to provide the following:
1) Itemized bills from all medical providers
2) Explanations of Benefits (EOB’s) from your medical insurance
company
All injuries must be reported to a staff athletic trainer. We will advise the student-athlete of the protocol that is recommended for
treatment and referral, and as appropriate, steps necessary to best insure proper payment by all insurance parties involved. Please
visit the student health center website to learn how to self-file charges incurred at the Student Health Center (SHC). The SHC
charges are eligible for insurance coverage, but are not submitted by the provider. Please note that charges incurred for services
at the SHC will be placed on the UNCG Student Account and lack of payment could affect future class registration, graduation
etc. At no time should the student-athlete seek medical treatment without the prior approval of the Athletic Trainer. This action
will jeopardize and/or remove responsibility from UNCG and its excess accident insurance company for payment of medical
bills.
Your signature on this letter indicates that you have read, understand and will comply with all that is stated above. Any false information will nullify UNCG from responsibility regarding any medical bills.
“I, _______________________________________ have read the above letter and understand that UNCG is responsible on a
secondary basis only for injuries which occur in an official UNCG athletic practice or competition. I also verify, that all of the
insurance information I have provided is correct and complete.”
_______________________________________
Student-Athlete Signature
_______________________________________________
Parent Signature
______________________
UNCG Student ID #
_________________
Date
_________________
Date
Appendix I
2016-2017 UNCG Intercollegiate Athletics Agreement,
Injury Release, Assumption of Risk, and Athlete Responsibility Form
UNCG Intercollegiate Athletic Sports:
Baseball, Basketball, Cheerleading, Cross Country, Dance, Golf, Soccer, Softball, Tennis, Track & Field, Volleyball
I am aware that trying out for, practicing or playing in any sport can be a dangerous activity involving MANY RISKS
OF INJURY. I understand the inherent potential dangers and risks of trying out for, playing and practicing in the above
intercollegiate sports may be catastrophic in nature and may include, but are not limited to, death; serious neck and spinal injuries which may result in complete or partial paralysis or brain damage; serious injury to virtually all bones, joints,
ligaments, muscles, tendons and other elements of the muscular-skeletal system, including loss of limb; and serious injury or impairment to other parts of my body, general health and well-being.
Because of the dangers of participating in any of the above sports, I recognize the importance of following the coach’s
instructions regarding playing techniques, training, rules of the sport and other team rules, and of following such instructions. I also realize that during my entire athletic career at UNCG I have a responsibility to my own physical well being
and must accurately report any injury in a timely manner to the UNCG Sports Medicine Staff. I will follow the guidelines established by the UNCG Sports Medicine Staff for rehabilitation from any injury. If I have any questions regarding my injury or care, I will ask the UNCG Sports Medicine Staff. I will also abide by the rules of the sport in which I
participate. I realize that adherence to these responsibilities in no way assures me of avoiding or lessening all injuries,
including those of catastrophic nature, but by following them, I may decrease the severity of some injuries.
In consideration of UNCG permitting me to try out for, practice, play or otherwise participate in the above listed intercollegiate sports and to engage in all activities related to the team, including, but not limited to practicing, playing and
traveling, I hereby voluntarily assume all risks associated with participation and agree to hold harmless The University
of North Carolina at Greensboro, its agents, officers and employees including, but not limited to, the UNCG Athletics
staff from any and all liability, claims, causes of action or demands of any kind and any nature whatsoever which may
arise by or in conjunction with my participation in any activities related to the UNCG Intercollegiate Athletics Program
except in the event of their gross negligence. The terms of this Agreement shall serve as a release and assumption of risk
for my heirs, estate, executor, administrators, assignees and all members of my family.
To the best of my knowledge, I am in good health and suffer no disability or condition which renders my participation in
the sport(s) or other athletics activity medically inadvisable, or otherwise limits my ability to participate in such sport(s)
or athletics activity without restriction.
I hereby authorize the coach or other appropriate UNCG personnel to obtain in my behalf first aid, emergency medical
care, or if necessary admission to an accredited hospital, when such care is necessary for the treatment of any injuries I
may sustain while participating in any activity associated with UNCG intercollegiate sports, including practices, competition and travel. I also hereby consent to the administration of emergency medical treatment in the event I am unable
subsequent to such injury to give such consent as otherwise necessary.
Name_________________________________________________
Date of Birth _________________
Signature_______________________________________________
Date ________________________
Parent/Guardian Signature _________________________________
(if student-athlete is less than 18 years of age)
Date_________________________
Appendix J
UNIVERSITY OF NORTH CAROLINA at GREENSBORO SPORTS MEDICINE
Sickle Cell Trait Screening Declination and Release of Claims
**Must submit this form along with Sickle Cell Results
(signing this form is NOT a replacement for testing, still must have Sickle Cell trait screening)
About Sickle Cell Trait:
Sickle cell trait is an inherited condition of the oxygen-carrying protein, hemoglobin, in the red blood cells.
Sickle cell trait is a common condition (> three million Americans).
Although Sickle cell trait is most predominant in African-Americans and those of Mediterranean, Middle Eastern, India, Caribbean, and
South and Central American ancestry, persons of all races and ancestry may test positive for sickle cell trait.
Sickle cell trait is usually benign, but during or after exercise, hypoxia(lack of oxygen) in the muscles may cause sickling of red blood cells
(red blood cells changing from a normal disc shape to a crescent or “sickle” shape), which can accumulate in the bloodstream and
“logjam” blood vessels, leading to collapse, personal injury and/or DEATH from the rapid breakdown of muscles starved of blood.
If the UNCG Sports Medicine Staff and the student-athlete’s coaches are made aware that a student-athlete has sickle cell trait, then collapse, personal injury and/or DEATH from exercise may be avoided or decreased if the student-athlete follows the directives of the
Staff and his/her medical professionals. Such directives may include, but not be limited to, reduced or modified activity during practice and/or games.
Sickle Cell Screening:
If the student-athlete does not have knowledge of their sickle cell trait status, the NCAA recommends that screening is performed. In order
to decrease the risk of collapse, personal injury and/or DEATH to its student-athletes, the University of North Carolina Greensboro
requires that all student-athletes who do not know their sickle cell status undergo the screening.
I ,______________________________, (parent or guardian name here if student-athlete is under 18)understand and
acknowledge that, in order to decrease the risk of collapse, personal injury and/or DEATH to its student-athletes the
University of North Carolina at Greensboro recommends that all student-athletes have knowledge of their sickle cell trait
status. Additionally, I have read and fully understand the aforementioned facts about sickle cell trait and sickle cell trait
testing. I understand that exercising without knowledge of sickle cell trait status can increase the risk of collapse, personal
injury and/or DEATH during or after exercise.
I hereby affirm that I have fully and accurately disclosed in writing any prior medical history and/or knowledge of sickle
cell trait status to UNCG Athletic Training staff.
I do not wish to undergo sickle cell trait testing (in the case of a minor, the parent or guardian does not wish the minor to
undergo sickle cell trait testing) through UNCG, as I (or my dependent) has been screened previously and I am able to provide these results. I (or in the case of a minor the parent or guardian) voluntarily agree to release, indemnify and hold harmless, regardless of their negligence, the State of North Carolina, the University of North Carolina at Greensboro, its officers,
employees, agents and volunteers from any and all costs, liabilities, expenses, claims, demands, or causes of action on account of any loss, personal injury or DEATH that might result from this decision to not be screened for sickle cell trait and/
or from any incorrect information that I or any person on my behalf provided to UNCG Athletic Training staff about sickle
cell trait status.
I have read and signed this document with full knowledge that I may be giving up rights that I may otherwise be entitled to
if I had not signed it. I am at least 18 years of age and competent to sign this waiver.
_________________________________________
Student-Athlete Signature
____________________________________
Date
_________________________________________
Sport
____________________________________
University ID#
_________________________________________
Parent/Guardian Signature
_________________________________________
____________________________________
Date
____________________________________