UNIVERSITY OF NOTRE DAME

STUDENT ATHLETE MEDICAL TREATMENT

NOTICE, WAIVER, AND CONSENT

You are hereby advised to read the following language carefully and thoroughly, as it relates to medical care and

treatment that may be provided to you as a student-athlete and also concerns how information about your medical

condition may be obtained and shared by the University of Notre Dame (“University”). If you are under 18 years

of age, your parent or legal guardian must sign and agree to this language. If you elect not to sign and agree

reasonably necessary by such medical providers: University Athletic Training Staff, University Physicians/Medical

Consultants, and any other medical provider deemed advisable by the University. This treatment may include

preventive care, first aid, primary care, mental health care, rehabilitation, and emergency treatment. I grant

permission to hospitalize me if deemed necessary by one of the medical providers identified in this paragraph. I

also grant each of the medical providers identified in this paragraph authority to disclose to each of the other

medical providers identified in this paragraph information about me, my medical insurance status, and my

medical history (including mental health history) as necessary or reasonably requested in order to arrange for or

facilitate the provision of treatment or medical care to me.

(2) AUTHORIZATION FOR RELEASE OF MEDICAL CONDITION

personnel at the University as they deem necessary. In addition, I authorize personnel of the University to share

information about my medical condition with members of the media as such condition relates to my past, present,

or future participation in intercollegiate athletics at the University for the purpose of responding to media inquiries.

(3) SHARED RESPONSIBILITY FOR SAFETY

I understand that there is certain inherent risk involved in participating in intercollegiate athletics as a student-

athlete, including serious bodily injury and/or death, and that I share responsibility for minimizing the risk of injury

to others and myself. I must promptly report any injury I have suffered (including any signs or symptoms of a

concussion, regardless of whether any such signs or symptoms are related to participation in intercollegiate

I understand that I must report to the appropriate personnel of the University’s Athletics Department any problems

in the condition or usefulness of equipment that I use. I agree to abide by instructions and guidelines provided to

me by personnel of the University’s Athletics Department and by any official or other authority with oversight of

athletic events as such instructions and guidelines relate to my medical condition, safety, and general participation

in intercollegiate athletics.

(4) ATHLETICS MEDICAL PAYMENT PROGRAM REQUIREMENTS, TERMS, AND

CONDITIONS

FOR COVERAGE UNDER THE TERMS OF THE PROGRAM. I AGREE TO KEEP THE UNIVERSITY

INFORMED AT ALL TIMES AS TO MY PRIMARY INSURANCE COVERAGE AND TO RESPOND

PROMPTLY TO ANY UNIVERSITY REQUEST FOR INFORMATION ABOUT SUCH COVERAGE. IF

PAYMENT FROM AN INSURANCE PROVIDER IS RECEIVED BY ME OR ON MY BEHALF FOR A COST

THAT HAS BEEN, IS BEING, OR WILL BE PAID BY THE UNIVERSITY UNDER THE PROGRAM, I

AGREE THAT I SHALL SEND SUCH PAYMENT OR ITS MONETARY EQUIVALENT TO THE

UNIVERSITY.

I also understand that a student-athlete’s eligibility for secondary insurance coverage by the University and under

the Program, and any claims for payment made by a student-athlete or on a student-athlete’s behalf under such

I understand that, in order to submit a claim for payment under the Program and to facilitate the processing of such

claims, any medical bills that are received by a student-athlete or on a student-athlete’s behalf for athletic/play

practice-caused injuries and illnesses, and records of any payments or denial of payments received by a student-

athlete or on a student-athlete’s behalf in relation to such injuries from any insurance company providing personal

health insurance coverage for which the student-athlete is eligible, MUST be forwarded promptly to the following

address:

Notre Dame Sports Medicine

University Athletic Training Staff

voluntarily and/or with my consent, and I agree that such information may also be used by the University’s Athletic

Training Staff for the purpose of monitoring my medical condition and any associated care or course of treatment.

(6) AUTHORIZATION TO OBTAIN AND DISCLOSE MEDICAL RECORDS UNDER THE

ATHLETICS MEDICAL PAYMENT PROGRAM

I acknowledge that the University utilizes the services of a third party administrator (“TPA”) to help process claims

under the Program. I authorize the University to share any information about my medical condition with the TPA

for the purpose of processing any claim that I submit or that is submitted on my behalf. With respect to each claim

submitted by me or on my behalf to the University under the Program, I grant the University and the TPA my

consent to disclose any information about me that is requested or needed to process the claim. Under this consent,

such information may be disclosed by the University or the TPA to any person or entity that requests or needs the

I HEREBY AUTHORIZE MY PRIVATE INSURANCE COMPANY TO SEND PAYMENT DIRECTLY TO

THE UNIVERSITY, TO ANY FACILITY WHERE MEDICAL SERVICES WERE RENDERED, OR TO ANY

PROVIDER THAT RENDERED MEDICAL SERVICES.

SIGNATURE AND ACKNOWELDGEMENT OF UNDERSTANDING

By signing below, I acknowledge and agree to the following:

PROGRAM. I acknowledge that, collectively, these paragraphs are referred to as the Numbered

Paragraphs.

• If I am the student-athlete named below, I understand the terms of the Numbered Paragraphs and

agree to them freely and voluntarily.

• If I am signing below on behalf of the student-athlete named below because he/she is under 18 years

of age:

o I attest that I am the parent or legal guardian of the student-athlete.

o I understand that I am standing in the place of the student-athlete by signing below, such that

all of the terms of the Numbered Paragraphs will apply to the student-athlete as if the student-

athlete signed below and his/her signature was legally valid and binding.

STUDENT-ATHLETE NAME (Printed) STUDENT-ATHLETE SIGNATURE DATE

_______________________________________ ____________________________________________

PARENT/GUARDIAN NAME (Printed) PARENT/GUARDIAN SIGNATURE DATE

NOTE: A parent or legal guardian of the student-athlete named must sign in addition to the student-athlete if

the student-athlete is under 18 years of age.