On-Campus Evaluation (OCE) Release STEP 1: PROSPECT ...
On-Campus Evaluation (OCE) Release STEP 1: PROSPECT INFORMATION PROSPECT NAME:
EMAIL:
HOME PHONE:
CELL PHONE:
SCHOOL NAME:
DATE OF BIRTH: SCHOOL TYPE:
SCHOOL CITY & STATE:
High School
2-yr College
Prep School
*4-yr College
SCHOOL SEASON COMPLETED:
*must have a release
Yes IF YES, ATTACH A COPY OF YOUR SCHEDULE *No *If “no”, you cannot participate HAVE YOU EXHAUSTED YOUR ELIGIBILITY AT THIS CURRENT SCHOOL? Yes IF YES, ATTACH A COPY OF YOUR TRANSCRIPT *No *If “no”, you cannot participate By signing below I confirm the information above is truthful and complete. Prospect Name (Please Print)
Prospect Signature
Date
STEP 2: MEDICAL EXAM HAVE YOU HAD A MEDICAL EXAM IN THE LAST 6 MONTHS: (OR WITHIN 6 MONTHS OF THE START OF THE SCHOOL SEASON YOU JUST COMPLETED) DO YOU HAVE HEALTH INSURANCE:
Yes ATTACH A COPY OF YOUR MEDICAL EXAM *No *If “no”, you cannot participate
Yes ATTACH A COPY OF THE FRONT & BACK OF YOUR INSURANCE CARD *No *If “no”, you cannot participate
NAME OF INSURANCE CARRIER:
POLICY NUMBER:
STEP 3: SICKLE CELL TESTING I understand and acknowledge that the NCAA and Texas State University recommend that I know my sickle cell trait status. I further understand that before I may participate in an OCE at Texas State, I am required to: (1) disclose documented results from a sickle cell trait test; OR (2) decline the test and sign release. Please select one: DISCLOSURE OF DOCUMENTED RESULTS ATTACH PROOF OF YOUR SICKLE CELL TEST
Recognizing that my physical condition depends on an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries, ailments, or disabilities experienced, I affirm that I have fully disclosed, in writing, any prior medical history or knowledge of sickle cell trait status to Texas State University’s athletic training personnel.
RELEASE AND INDEMNITY
I confirm that I do not wish to undergo sickle cell trait testing or provide documentation of a previous sickle cell solubility test. I voluntarily release, discharge, indemnify and agree to indemnify and hold harmless Texas State University and its employees and agents from all costs, liabilities, expenses, claims, or demands against them that result, directly or indirectly, from my decision not to follow the recommendation that I be aware of my sickle cell trait status and my decision not to share this information with the university’s athletic training personnel.
By signing below, I confirm that I have read the above information regarding sickle cell trait testing and understand the significance of my decision when making my selection above. Prospect Name (Please Print)
Prospect Signature
Date
Parent/Legal Guardian Name (Please Print) (If prospect is under 18 years of age)
Parent/Legal Guardian Signature (If prospect is under 18 years of age)
Date
On-Campus Evaluation (OCE) Release STEP 4: ACTIVITY RELEASE and INDEMNITY AGREEMENT Releasees:
The Board of Regents, Texas State University System, Texas State University – San Marcos, and all regents, employees, agents, and officers for these entities.
Release:
In consideration for facilitating my participation in the activity described above, I release, discharge, and agree not to sue Releasees for any claims, demands, actions and causes of action arising out of any loss or damage to my property and any injury, including death, that I may sustain, whether or not caused by the negligence of the Releasees, while participating in the activity, or while in transportation to and from the activity.
Risks:
To the best of my knowledge, I can participate in this activity. I am aware of the risks and hazards connected with the activity, and I elect to participate voluntarily and engage in this activity knowing that the activity may be hazardous to my property and me. I voluntarily assume full responsibility for property loss or damage, and for personal injury, including death, that I may sustain as a result of being engaged in this activity, whether or not caused by negligence of Releasees.
Indemnity:
I also agree to indemnify and hold harmless the Releasees from any loss, liability, damage or costs, including court costs and attorney’s fees, that they may incur due to my participation in the trip whether caused by the negligence of Releasees or otherwise. For example, I specifically agree to indemnify and hold harmless the Releasees from losses they may incur as a result of my injuring another person or damaging another person’s property while participating in the activity.
Intent:
I intend that this Activity Release and Indemnity Agreement bind not only me, but also the members of my family and my spouse (if any), if I am alive, and my heirs, assigns, and personal representatives, if I am not alive. I intend this as a release, discharge and promise not to sue the Releasees. I further agree that this Activity Release and Indemnity Agreement should be construed in accordance with the laws of the State of Texas.
By signing this release, I acknowledge that I have read and agree to the Activity Release and Indemnity Agreement. I am voluntarily signing this release as my own free act. Prospect Name (Please Print)
Prospect Signature
Date
Parent/Legal Guardian Name (Please Print) (If prospect is under 18 years of age)
Parent/Legal Guardian Signature (If prospect is under 18 years of age)
Date
TO BE ELIGIBLE TO PARTICIPATE IN THE OCE, YOU MUST HAVE FILLED OUT THIS FORM COMPLETELY AND ATTACHED ALL OF THE FOLLOWING DOCUMENTS LISTED BELOW
STEP 4: CHECKLIST Game schedule from this past season Transcript Medical exam Copy of Insurance Card Sickle cell test (or you have declined the test by signing the waiver on this form) Permission to Contact (only applicable to those prospects currently attending a 4-year college)
FAX ALL INFORMATION TO: 512-245-8807
IF YOU ARE APPROVED FOR THE OCE, YOU WILL RECEIVE CONFIRMATION FROM THE TXST BASKETBALL STAFF.
EMAIL:
HOME PHONE:
CELL PHONE:
SCHOOL NAME:
DATE OF BIRTH: SCHOOL TYPE:
SCHOOL CITY & STATE:
High School
2-yr College
Prep School
*4-yr College
SCHOOL SEASON COMPLETED:
*must have a release
Yes IF YES, ATTACH A COPY OF YOUR SCHEDULE *No *If “no”, you cannot participate HAVE YOU EXHAUSTED YOUR ELIGIBILITY AT THIS CURRENT SCHOOL? Yes IF YES, ATTACH A COPY OF YOUR TRANSCRIPT *No *If “no”, you cannot participate By signing below I confirm the information above is truthful and complete. Prospect Name (Please Print)
Prospect Signature
Date
STEP 2: MEDICAL EXAM HAVE YOU HAD A MEDICAL EXAM IN THE LAST 6 MONTHS: (OR WITHIN 6 MONTHS OF THE START OF THE SCHOOL SEASON YOU JUST COMPLETED) DO YOU HAVE HEALTH INSURANCE:
Yes ATTACH A COPY OF YOUR MEDICAL EXAM *No *If “no”, you cannot participate
Yes ATTACH A COPY OF THE FRONT & BACK OF YOUR INSURANCE CARD *No *If “no”, you cannot participate
NAME OF INSURANCE CARRIER:
POLICY NUMBER:
STEP 3: SICKLE CELL TESTING I understand and acknowledge that the NCAA and Texas State University recommend that I know my sickle cell trait status. I further understand that before I may participate in an OCE at Texas State, I am required to: (1) disclose documented results from a sickle cell trait test; OR (2) decline the test and sign release. Please select one: DISCLOSURE OF DOCUMENTED RESULTS ATTACH PROOF OF YOUR SICKLE CELL TEST
Recognizing that my physical condition depends on an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries, ailments, or disabilities experienced, I affirm that I have fully disclosed, in writing, any prior medical history or knowledge of sickle cell trait status to Texas State University’s athletic training personnel.
RELEASE AND INDEMNITY
I confirm that I do not wish to undergo sickle cell trait testing or provide documentation of a previous sickle cell solubility test. I voluntarily release, discharge, indemnify and agree to indemnify and hold harmless Texas State University and its employees and agents from all costs, liabilities, expenses, claims, or demands against them that result, directly or indirectly, from my decision not to follow the recommendation that I be aware of my sickle cell trait status and my decision not to share this information with the university’s athletic training personnel.
By signing below, I confirm that I have read the above information regarding sickle cell trait testing and understand the significance of my decision when making my selection above. Prospect Name (Please Print)
Prospect Signature
Date
Parent/Legal Guardian Name (Please Print) (If prospect is under 18 years of age)
Parent/Legal Guardian Signature (If prospect is under 18 years of age)
Date
On-Campus Evaluation (OCE) Release STEP 4: ACTIVITY RELEASE and INDEMNITY AGREEMENT Releasees:
The Board of Regents, Texas State University System, Texas State University – San Marcos, and all regents, employees, agents, and officers for these entities.
Release:
In consideration for facilitating my participation in the activity described above, I release, discharge, and agree not to sue Releasees for any claims, demands, actions and causes of action arising out of any loss or damage to my property and any injury, including death, that I may sustain, whether or not caused by the negligence of the Releasees, while participating in the activity, or while in transportation to and from the activity.
Risks:
To the best of my knowledge, I can participate in this activity. I am aware of the risks and hazards connected with the activity, and I elect to participate voluntarily and engage in this activity knowing that the activity may be hazardous to my property and me. I voluntarily assume full responsibility for property loss or damage, and for personal injury, including death, that I may sustain as a result of being engaged in this activity, whether or not caused by negligence of Releasees.
Indemnity:
I also agree to indemnify and hold harmless the Releasees from any loss, liability, damage or costs, including court costs and attorney’s fees, that they may incur due to my participation in the trip whether caused by the negligence of Releasees or otherwise. For example, I specifically agree to indemnify and hold harmless the Releasees from losses they may incur as a result of my injuring another person or damaging another person’s property while participating in the activity.
Intent:
I intend that this Activity Release and Indemnity Agreement bind not only me, but also the members of my family and my spouse (if any), if I am alive, and my heirs, assigns, and personal representatives, if I am not alive. I intend this as a release, discharge and promise not to sue the Releasees. I further agree that this Activity Release and Indemnity Agreement should be construed in accordance with the laws of the State of Texas.
By signing this release, I acknowledge that I have read and agree to the Activity Release and Indemnity Agreement. I am voluntarily signing this release as my own free act. Prospect Name (Please Print)
Prospect Signature
Date
Parent/Legal Guardian Name (Please Print) (If prospect is under 18 years of age)
Parent/Legal Guardian Signature (If prospect is under 18 years of age)
Date
TO BE ELIGIBLE TO PARTICIPATE IN THE OCE, YOU MUST HAVE FILLED OUT THIS FORM COMPLETELY AND ATTACHED ALL OF THE FOLLOWING DOCUMENTS LISTED BELOW
STEP 4: CHECKLIST Game schedule from this past season Transcript Medical exam Copy of Insurance Card Sickle cell test (or you have declined the test by signing the waiver on this form) Permission to Contact (only applicable to those prospects currently attending a 4-year college)
FAX ALL INFORMATION TO: 512-245-8807
IF YOU ARE APPROVED FOR THE OCE, YOU WILL RECEIVE CONFIRMATION FROM THE TXST BASKETBALL STAFF.
