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Concordia College Emergency/Insurance Information
Please print form, fill out completely and return to:
Stephanie Brandt  - Athletic Trainer
Concordia College
901 South 8th Street
Moorhead, MN 56562

Athlete's Name Date of Birth
     Last,   First,   MI      
Sports Participating in
Social Security #  
College Address Phone #
   
 
Parent/Guardian Name Phone #
Address  
   
EMERGENCY CONTACT IN NO ANSWER ABOVE
Name
Relationship  Phone #
Known Allergies Last Tetanus Booster
Current Prescriptions
Significant Midical Conditions
INSURANCE INFORMATION
Name of Policy Holder  
Company
Group #
Policy/ID#
Mailing Address (for claims)
                                               Street        City    State    Zip                            800 Phone #
Do you have insurance restrictions as to a physician you can see? Yes No
If yes, which group of physicians can you see? Orthopedic Associates Merit Care Dakota/Innovis
Do you have insurance restrictions as to where you need to receive physical therapy? Yes No
If yes, which group of physical therapists can you see? Health South Merit Care Dakota/Innovis

 
Medical Authorization This athlete/parent gives consent for the team physician, consulting physician and/or appropriate member of the sports medicine staff of Concordia College to examine records, or be in consultation concerning examination or treatment of the athlete for the express purpose of evaluating the medical and/or physical fitness for participation in, or continued participation in any athletic program at Concordia College.  The athlete/parent also gives permission for acceptable diagnostic, therapeutic and emergency operative procedures to be carried out in the treatment of illness and injury sustained while a member of a Concordia College athletic team.


Signature of Athlete (Parent if not 18)    Date

 

 
Athletic Insurance Policy
Athletic insurance is provided by Concordia College for the benefit of our intercollegiate student-athletes.  For the 2001 -- 2002 school year, athletic insurancecoverage is provided by ReliaStar Life Insurance company and administered by Student Assurance Services.  This coverage is offered on an "excess" basis only, which means ReliaStar Life Insurance Company will only cover expenses after the athlete's primary carrier has been used to its fullest extent.  Primary coverage would include parental insurance under which the student-athlete is covered as an eligible dependent.
The deductible for this insurance policy is $500 per injury.  If the student-athlete is injured in a separate incident at a later date, he or she will be required to pay another $500 deductible before ReliaStar Life Insurance will begin to cover expenses.  All claims must be filed within 30 days of injury.
 

The above statements are true to the best of my knowledge.  This athlete gives consent for the team physician, consulting physician, Concordia Student Health Personnel and/or appropriate member of the sports medicine staff of Concordia College to examine records, or be in consultation concerning examination or treatment of the athlete for the express prupose of evaluating the medical and/or physical fitness for participation in, or continued participation in any athletic program at Concordia College.  The athlete/parent also gives permission for acceptable diagnostic, therapeutic and emergency operative procedures to be carried out in the treatment of illness and injury sustained while a member of a Concordia College Athletic Teams.
 
 


Signature of Athlete (Parent if not 18)    Date

 

 
 

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