New Student Packet by Eureka College

NEW STUDENT

inside welcome mark your calendar 2012-13 academic calendar general information important contacts checklist personal data health questionnaire immunizations insurance verification student athletes information athletic physical parking registration parking & maps

welcome

Dear Eureka College Student,

! Welcome to Eureka College! We look forward to having you join our community this fall. We know that you have a lot of questions right now, and hope to start answering some of them with this mailing. Enclosed is information that you will find useful as you begin the transition process at Eureka. It includes the following:

•

Information on student services provided by the college

•

Personal and Medical Information sheets (four need to be returned)

•

Parking Registration Form

•

Student Athlete Forms (athletes only)

Please complete and return the above forms to the Office of Student Programs and Services at Eureka College or you may bring them with you when you attend a Jump Start Day (freshmen) or Transfermation Day (transfers) this spring or summer. The above forms are also available on the Eureka College website at www.eureka.edu/admissions/incoming students. I urge you to take time to review all this information, and to share this information with your family. Should you or your family have questions, please do not hesitate to contact me or the Student Programs and Services staff at (309) 467-6420. I look forward to meeting you soon! Sincerely yours,

Brooke Campbell Dean of Students

markyourcalendar

The information provided in this packet will hopefully address many of the questions you may currently have about your enrollment at Eureka College. If appropriate, your family should also be aware of the information it contains. If you have any questions, please contact the Office of Student Programs and Services at (309) 467-6420.

Residence Hall Move-In August 18

Welcome Week August 18 – 21

An opportunity for incoming Eureka College students to learn more about the campus, academic programs, and what to expect at Eureka College. Mandatory for new students.

Homecoming October 1– 6

A week long event ending with the big game on Saturday. Parents and families are encouraged to join the students and campus community in this celebration of the “Spirit of Eureka.”

Graduation May 10 – 11

Baccalaureate is on Friday, May 10, 2013. Graduation is in Rinker Outdoor Theatre (weather permitting) on Saturday, May 11, 2013.

AUGUST SEPTEMBER

No Classes (Labor Day) September 3

OCTOBER

Homecoming Week October 1-5 Homecoming Game 6 Fall Break 22-23

NOVEMBER

DECEMBER

Residence Halls Close 5pm Thanksgiving Break Begins Residence Halls Open 8am Classes Resume

Study Day December 6 Finals for Semester 1 7, 8,10,11 Residence Halls Close 5pm 11

JANUARY

New Student Orientation Residence Halls Open 8am Classes Begin (Semester 2) No Classes, Martin Luther King Jr. Day

MARCH

Residence Halls Close 5pm Spring Break Residence Halls Open 8am Classes Resume Easter Break

APRIL MAY

November 20 21 25 26

January 13 13 14 21

2012-13academiccalendar

Residence Halls Open August 18 Welcome Week 18-21 Classes Begin (Semester 1) 22

March 8 9-17 17 18 29

Easter Break April 1 Classes Resume 2 Honors Ceremony 21

Study Day May 2 Finals for Semester 2 3, 4, 6, 7

generalinformation

COMPUTERS All resident hall rooms have fiber connection to the campus network and to the Internet. Additionally, WiFi connectivity is available in a majority of the residence hall footprint. If you plan to use your own computer, make sure you have a network port on your computer. Most computers now have built-in network ports. The Collegeâ&#x20AC;&#x2122;s Information Technology staff provides assistance with network connections. Students without computers have access through the computer labs in Vennum-Binkley Science Hall, Burgess Hall, Melick Library, Learning Center, and a 24-hour lab in Ben Major Center. These computer labs are open to all Eureka College students. The Information Technology Department can only provide connectivity to the campus network and the Internet. If the issue is with a studentâ&#x20AC;&#x2122;s computer (a bad hard drive, viruses/spyware, applications, programs on their computer or some other hardware problem) they will need to resolve that issue first. Only then can the Information Technology Department assist with any connectivity issues. Students are encouraged to bring their own desktop or laptop, and maintain it in proper working order.

CAMPUS MAIL Every freshman and residential student is given a campus mailbox which is located in the Donald B. Cerf Center. Ivy Residence Hall has its own mail receptacle. It is important to check your mail on a daily basis as faculty, staff and students utilize the campus mailboxes for distribution of notices, letters, and announcements. Your campus box number must be included on incoming mail in order to ensure proper delivery. Incoming mail should be addressed as follows: Studentâ&#x20AC;&#x2122;s Name Eureka College # (Campus Box Number) 300 E. College Avenue Eureka, IL 61530-1500 A transfer commuter student may request a campus mailbox through the Mailroom Office. Commuter campus mailboxes will be issued on a first come basis depending on availability.

E-MAIL Additionally, every student is provided an email address that is activated once the student is enrolled. It is also important to check your email account daily as instructors and offices regularly communicate by email with important announcements.

PARKING Students may bring an automobile to campus. All automobiles must be registered with the Office of Student Programs & Services. The parking pass (obtained when the vehicle is registered) must be displayed at all times.

All students must submit a completed health questionnaire to the Office of Student Programs and Services prior to enrollment. Illinois State law requires that all students submit a record of current required immunizations. Students participating in intercollegiate athletics must complete the enclosed Athletic Information Sheet and Athletic Pre-participation Physical Evaluation, which includes proof of a physical examination performed by a licensed physician. Eureka College contracts with Eureka Community Hospital for health clinic services. All students, whether residential or commuting, may use the clinic at Eureka Community Hospital, as long as x-rays and extensive lab work (beyond CBC, throat culture and urinalysis) are not needed. There will be a co-pay fee charged to the student’s account through the Business Office for each visit to the clinic. The co-pay fee for the 20122013 school year will be $10. The clinic’s hours of service are 6:00 a.m. to 10:00 p.m. daily throughout the academic school year. Services beyond basic evaluation and treatment and services outside of clinic hours are charged to the student’s health insurance. Starter medicine packets and sport physicals are charged through the student’s college account. Students must show their college ID every time they visit the clinic.

generalinformation

HEALTH INFORMATION

TUITION MANAGEMENT As a service, a student’s expenses may be spread over ten (10), nine (9), or eight (8) monthly payments, without interest. The only cost is a $65 enrollment fee. This option will enable you to conserve savings and more easily budget costs. It is offered in cooperation with TUITION MANAGEMENT SYSTEMS (TMS), a nationwide leader in helping families afford education. Information on this program may be obtained by calling the Admissions Office, 1-888-4EUREKA, the Business Office at 1-800-548-9144, or by calling TMS direct, at 1-800-356-8329. ALTERNATIVE LOAN (Student’s Name – Parent Co-signer) PLUS LOAN FOR UNDERGRADUATE STUDENTS (Parent’s Name) Contact the Eureka College Financial Aid Office on their website, www.eureka.edu at 1-888-4EUREKA or by e-mail eraid@eureka.edu Payments may also be made by Master Card/VISA/Discover

Note:

Students are not allowed to take a final exam early at the end of any semester to accommodate transportation. A student wishing to make arrangements for transportation should consider the final exam schedule and the carrier’s schedule.

generalinformation

ACCIDENT AND SICKNESS INSURANCE REQUIREMENT Eureka College participates in a program of Accident and Sickness Insurance designed especially for students. The annual charge for the 2011-2012 school year was set at $520 (12-month) and $340 (second semester only). The 2012-2013 cost for this coverage will be determined after June 1st, 2012. All full-time students attending the College are required to participate in this program unless an insurance waiver card as described below is furnished. Students may also secure family coverage. Information regarding family coverage is available through the Eureka College Business Office. An insurance waiver card requesting insurance verification will be sent with the student’s statement of student account in July. The waiver must be filled out, signed, and returned each year at the beginning of the fall semester. Failure to return the waiver card with proof of insurance coverage will result in the purchase of the college sponsored health and accident insurance plan. The premium will be charged to the student’s account. A medical expense benefit schedule for the college sponsored insurance plan is also sent with each student’s statement in July. For additional information, students may contact the Business Office at (309) 467-6309 or 1-800-548-9144.

ATHLETIC INSURANCE REQUIREMENT NCAA requires students participating in intercollegiate athletics to purchase additional insurance coverage through the College. The 2012-2013 fees are estimated to be as follows:

Football = $275.00 Basketball/Soccer = $165.00 All other sports = $140.00 (Athletic Insurance fees are tentative and subject to change.) If a student is involved in more than one athletic program, the student does not have to pay a fee for each. The highest applicable fee must be paid. Further information is available by calling the Business Office at (309) 467-6309 or 1-800-548-9144.

PROPERTY PROTECTION It is strongly recommended that all residential students have some form of insurance coverage for their personal property. Coverage may be available to students through their parents’ Homeowners Policy. Eureka College is not responsible for replacing a student’s belongings as a result of damage or theft.

Business Office/Human Resources: (309) 467-6305 or 1-800-548-9144 Provostâ&#x20AC;&#x2122;s Office: (309) 467-6301 Financial Aid Office: (309) 467-6310 Records Office: (309) 467-6303 Student Programs and Services: (309) 467-6420

Academic Advising (309) 467-6302 Registrar

Financial Aid (309) 467-6311 Director of Financial Aid

Academic Concerns (309) 467-6301 Provost

Food Service (309) 467-6358 Director of Food Service

Athletics (309) 467-6377 Athletic Director Athletic Training (309) 467-6378 Athletic Trainer Billing Chief Financial Officer (309) 467-6305 Student Accounts Manager (800) 548-9144 Bookstore (309) 467-6426 Bookstore Manager Business Office/Campus Work (309) 467-6312 Human Resources Career Planning & Internships (309) 467-6413 Director of Career Services Care Packages/Birthday Treats (309) 467-6413 Student Foundation Advisor Counseling (309) 467-6429 Chaplain Course Scheduling (309) 467-6303 Registrar or Assistant Registrar

Health Services (309) 467-6420 Dean of Students

importantcontacts

Admissions: (309) 467-6350 or 1-888-4EUREKA

General Information (309) 467-3721 Switchboard Housing/Residential Life (309) 467-6419 Director of Residential Life Information Technology (309) 467-6451 Learning Resource Center (309) 467-6592 Director of Learning Center Library Services (309) 467-6382 Director of Melick Library New Student Orientation (309) 467-6436 Assistant Dean of First-year Programs Religious Life (309) 467-6429 Chaplain Student Activities (309) 467-6407 Director of Student Activities Student Services (309) 467-6420 Dean of Students

checklist

It is important that you complete the front and back of all documents in full and return the information to the Office of Student Programs and Services at the address below. Included in this packet is a Personal Data Document, Student Health Questionnaire, Immunization Form, and a Medical Insurance Verification Form. The Athletic Pre-participation Physical Evaluation and Athletic Information Sheet need to be completed if you are participating in a sport. The physicianâ&#x20AC;&#x2122;s signature is required. A full examination of the student must be completed by a physician. Identify all allergies and all current medications. In order to compete in any intercollegiate athletics, a physician must provide approval.

If any of the information changes while you are a student at Eureka College, please notify the Office of Student Programs and Services (SPS) and the Office of Records (Burrus Dickinson Hall). All information in this packet must be completed. Some of the information may need to be completed with your parents or spouse if applicable. We appreciate the time you take in completing all personal information requested.

CHECKLIST FORMS TO BE COMPLETED AND RETURNED: Personal Data Document Student Health Questionnaire Immunization Form Medical Insurance Verification

Should you have questions, please contact: Office of Student Programs and Services Eureka College 300 E. College Avenue Eureka, IL 61530-1500 Phone: (309) 467-6420

Student Programs and Services 300 E. College Ave., Eureka, IL 61530-1500 Name ______________________________________________________________________________ Permanent Address ___________________________________________________________________ City ____________________________________ State __________________ ZIP ________________ Telephone ___________________________________ Cell ___________________________________ Email ______________________________________________________________________________

personaldata

Return to:

Hometown Newspaper ____________________________ Phone ______________________________ Fax ________________________________________________________________________________

Parents/Other Information (Spouse, relative, or friend if Parent information does not apply.

FATHER

Required if student is under the age of 21)

MOTHER

Name _____________________________________ Name _____________________________________ Address:____________________________________ Address:____________________________________ __________________________________________ __________________________________________ (H) ______________________________________

(H) ______________________________________

(O) ______________________________________

I consent to share, upon request, the following information with: Financial Statement:

Academic Report:

Father Only

Mother Only

Both Parents

Self

Other: ____________________________

___________________________________________________ ______________________________ Signature Date â&#x20AC;&#x201C; Continued on back â&#x20AC;&#x201C;

personaldata

Mandatory Medical Information I consent to share, upon request, the following information with: Phone Number

Relationship

Name

_______________________________ ________________________ ___________________________ _______________________________ ________________________ ___________________________

If the student entering Eureka College is under eighteen years of age, the following permission to seek medical assistance when necessary is needed from the appropriate guardian. This permission remains on file in the Student Programs and Services Office.

In the event of any needed medical treatment, I, _____________________________________________, Name of Parent/Guardian

give my permission to Eureka College and/or its medical contractor to seek the necessary medical treatment for ________________________________________________________________________________. Name of Student

_________________________________________ Parent/Guardian Signature

STATEMENT OF INSURANCE All students attending Eureka College are required to show proof of health insurance prior to registration (see Medical Insurance Verification Form), or they must accept the insurance coverage offered by Eureka College. If a student does not demonstrate proof of insurance, he/she will be billed an irreversible insurance charge. If Election #2 is not checked, the Health and Sickness Insurance will be automatically billed. (Parental Group Insurance is primary in all cases.) ______ 1.

I elect the College-sponsored Health and Sickness insurance (Premium to be added to studentâ&#x20AC;&#x2122;s account).

______ 2.

I do not elect additional coverage under the Collegeâ&#x20AC;&#x201C;sponsored Insurance plan.

______ 3.

I realize that if I am an athlete, I must accept the NCAA Insurance Coverage. I realize that this is not the same insurance as provided by the Health and Sickness Insurance outlined in Elections #1 and #2.

Signature _____________________________________________________________________________ Parent/Guardian if student is under 18 _______________________________________________________

personaldata The Personal Data Document provides the college with basic information which initiates academic course work, billing, academic repairs, and emergency contact. It is imperative that you complete the front and back of this document.

PARENT/GUARDIAN INFORMATION Up-to-date information ensures delivery of Billing Statements and Academic Reports to the proper location. Also, see Medical Information below. INDEPENDENT STUDENTS should complete this information, noting their contact person.

CAR IDENTIFICATION INFORMATION Students should list information on all automobiles which may be brought to campus. This information allows campus security to validate visitor's parking and speed up response to student concerns relating to traffic and parking. Should the information change during enrollment at Eureka College, please contact the Office of Student Programs and Services. A parking permit is required of all students using college parking lots.

MEDICAL INFORMATION Eureka College requests the full name, relationship, and phone number of someone to whom emergency issues may be addressed. If the student entering Eureka College is under the age of 18, permission is required for medical services to be rendered by Eureka College or its contractor, if services are necessary.

STATEMENT OF INSURANCE All students attending Eureka College are required to show proof of health insurance prior to registration, or they must accept the insurance coverage offered by Eureka College.

studenthealthquestionnaire

In order to register for classes at Eureka College, the Student Health Questionnaire and Immunization Sheet must be completed and in the possession of the Office of Student Programs and Services. A student cannot attend classes or participate in or practice for intercollegiate or intramural competition unless this record is on file in the Office of Student Programs and Services. Because of Illinois State Department of Health requirements, it is important that these instructions be closely followed. Should it be necessary to provide further clarification, please attach additional information as necessary. Student Health Questionnaire: To be completed and signed by the student. Please check all indicated medical conditions which the student has had or is currently experiencing. Immunizations: To be completed by a physician (or health care professional licensed to provide immunization verification). The actual signature of the health care provider is required.

Diphtheria, Pertussis, and Tetanus (DPT, DT, or Td vaccine): The student must have received three doses, with the most recent dose within ten years of enrollment. Eureka College strongly prefers that the most recent dose be within six years of enrollment (Tetanus Toxoid vaccination does not meet this requirement). Measles (Rubella): Students must have had two immunizations and must have been immunized on or after their first birthday with the LIVE measles virus vaccine. Month, day, and year must be documented to leave no doubt that the person was immunized on or after their first birthday (laboratory evidence of measles or a physicianâ&#x20AC;&#x2122;s signed confirmation of disease history is acceptable). Individuals vaccinated prior to 1968 must show proof that a LIVE virus vaccine, without gamma globulin, was administrated. Rubella: Students must have received the rubella vaccine on or after their first birthday. Laboratory confirmation is acceptable. A history of disease is not acceptable as proof of immunity. Mumps: Students must have been immunized on or after their first birthday (physician confirmation is acceptable; laboratory confirmation is not acceptable). TB Skin Test: Required of all international students. Test must be within six months prior to entrance into Eureka College. Important Note: The actual signature of the health care provider is REQUIRED. A signature stamp is not acceptable for proof of immunization. The certificate of Child Health examination from the studentâ&#x20AC;&#x2122;s high school or Public Department of Health is acceptable for review by Eureka College. It is not necessary for students born before January 1, 1957 to demonstrate immunity. Athletic Physical Forms are to be completed by a physician ONLY IF STUDENT IS PARTICIPATING IN ATHLETICS.

Name:________________________________________________ Birthdate:___/___/___ Sex: Male Female Last First Middle In case of emergency, contact:____________________________________ Relationship:_____________________ Address:_______________________________ City:___________________ State: ______ Zip Code:___________ Telephone:

(H) _________________________________

(Cell) _________________________________

TO BE COMPLETED BY THE STUDENT If you are you Participating in Intercollegiate Athletics, what Sport(s)?_____________________________ Allergies? (Please list) ________________________________________________________________ Check any of the following medical conditions which you have had or are currently experiencing: Chicken Pox (If so, what year?_____ )

Mononucleosis

Cancer

Diabetes/Low Blood Sugar

Tuberculosis

Hepatitus

Asthma

Epilepsy/Convulsions

Depression/Anxiety

Heart Murmer

Anemia

Rhuematic Fever

Renal Disease

Low Blood Pressure

Hernia

Have you ever been treated by a physician (including osteopath, chiropractor, psychiatrist, ect.) during the last five years? Yes No If so, what was the treatment and result?__________________________________________________ Have you been diagnosed with a learning disability? Yes No

Have you ever or do you now have:

Dizzy or fainting spells Heat exhaustion, prostration, or stroke Chronic or persistant cough Shortness of breath after mild exertion Chest pain after exertion Frequent leg cramps Broken bone Head injury which required X-rays Back injury or recurrent low back Currently under a physicianâ&#x20AC;&#x2122;s care? Have you ever had any injury of: Shoulder â&#x20AC;&#x2030; Knee

Wrist Ankle

Hip

Yes No

Yes

studenthealthquestionnaire

Information on this form may be shared with appropriate college and state health personnel for health and educational purposes.

Do You:

Wear contact lens while participating in sports Wear a dental appliance Wear a corrective brace or support Take medication daily for any chronic disease Have any other medical problems not mentioned above? If so please explain: ________________________ Have you ever: Had surgery or been advised to have surgery? Explain: __________________________________________ Bled excessively after injury/tooth extraction? Been allergic to any medications? Had a physician advise you not to participate in sports? Been knocked unconscious?

I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE

SIGNATURE OF STUDENT ________________________________________

DATE_________________________

immunizations

To be completed by a physician or health care professional To be completed by a physician or health care professional Student’s Name: ________________________________________________________________________ Last First Middle Initial

Please provide the month, day, and year for every dose administered.

1. Diphtheria, Pertussis and Tetanus

___ /___ /___ ___ /___ /___ ___ /___ /___

2. Tetanus Boosters

___ /___/___

3. Combined Measles/Mumps/Rubella ___ /___ /___ ___ /___ /___ (MMR)

4. Rubeola (Red Measles) Live Virus

___ /___ /___

5. Mumps 6. TB Skin Test

___ /___ /___ ___ /___ /___

Required of International Students only.

Health provider signature(s)* (Physician, school health professional, or health official verifying that immunizations were given). __________________________________________________________________________________________ Signature

Date

__________________________________________________________________________________________ Signature

Date

*A signature stamp is not acceptable for proof of immunization.

1. Clinical diagnosis for Measles and Mumps is acceptable if verified by Physician, but not acceptable for Rubella. Measles ____ /____/____ Month Day Year

Mumps ____ /____/____ Month

Day

Year

2. Laboratory Confirmation of Measles or Rubella is acceptable. For mumps, laboratory evidence is not acceptable. Disease: __________________________________

Date: ____ /____ /_____ Month

Day

Year

Lab Result: ________________________________ Physician’s Signature: _______________________________

RECEIPT OF COMPLETED FORM IS REQUIRED BEFORE STUDENT IS ALLOWED TO ATTEND ATHLETIC PRACTICE OR REGISTER FOR CLASSES.

Date: _____________________________ Name: _____________________________________________________ Sport (if athlete): ____________________ Date of Birth: _____________________________ Home Address:___________________________________________ Home Phone: ( ______ ) _______ - ________ City: _________________________________________________________ State: ___________ ZIP: ___________ Parent Information (Required if student is covered under a parent’s policy. Athletes must complete information for both parents for secondary insurance processing.) Father/Guardian

MOTHER/GUARDIAN

Father’s Name:____________________________

Mother’s Name:___________________________

Address:_________________________________

________________________________________

Employer________________________________

Address:_________________________________

_______________________________________

Telephone: ( ______ ) _______ - __________

Medical Insurance

Company or Plan:_________________________

Address:_________________________________

_______________________________________

Policy Number: ___________________________

Telephone: ( _____ ) ______ - ___________ Is this plan an HMO or PPO? Yes No Is pre-authorization required Yes No to obtain treatment? Is a second opinion required Yes No before surgery?

insuranceverification

(This side of the form is required of ALL Eureka College students.)

Student Information (Required if student is covered under their own policy) NAHGA - Policy #201ON1A14 303 Amherst St., Nashua, NH 03063-1722 • 1-800-920-4456 Medical Insurance Company or Plan: ________________________________________________________________

(If you have no other insurance write “School Insurance Only” and check NAHGA box above)

Address: ____________________________________ Is pre-authorization required to obtain treatment? City/State/Zip:_______________________________ Is a second opinion required before surgery? Yes Policy Number: ______________________________ Is this plan an HMO or PPO? Yes No

Yes

Telephone: ( _____ ) ______ - ___________

insuranceverification

(This side of the form is required to be completed by all athletes at Eureka College.) AUTHORIZATION â&#x20AC;&#x201C; To Permit Use and Disclosure of Health Information This Authorization was prepared by First Agency, Inc. and Eureka College for purposes of obtaining information necessary to process a claim for benefits. Upon presentation of the original or a photocopy of this signed Authorization, I authorize, without restriction (except psychotherapy notes), any licensed physician, medical professional, hospital or other medical-care institution, insurance support organization, pharmacy, governmental agency, insurance company, group policyholder, employer or benefit plan administrator to provide First Agency, Inc., Eureka College or any agent, attorney, consumer reporting agency or independent administrator, acting on its behalf, all information concerning advice, care or treatment provided the patient, employee or deceased named below, including all information relating to, mental illness, use of drugs or use of alcohol. This Authorization also includes information provided to our health division for underwriting or claim servicing and information provided to any affiliated insurance company on previous applications. If this Authorization is for someone other than myself, that individual has given me authority to act on his/her behalf as explained below. I understand that I have the right to revoke this Authorization, in writing, at any time by sending written notifi cation to Eureka College or to First Agency at 5071 West H Avenue, Kalamazoo, MI 49009-8501. I understand that a revocation will not be effective to the extent we have relied on the use or disclosure of the protected health information or if my Authorization was obtained as a condition to determine my eligibility for benefits. Revocation requests must be sent in writing to the attention of the Claims Supervisor. I understand that First Agency, Inc. may condition payment of a claim upon my signing this authorization, if the disclosure of information is necessary to determine the level or validity of the claim payment. I also understand, once information is disclosed to us pursuant to this Authorization, the information will remain protected by First Agency, Inc. in accordance with federal or state law. This Authorization is valid from the date signed for the duration of the claim or one year if no claim has been filed. ___________________________________ ______________________________________ _____________ Name of Claimant (please print) Signature of Claimant (if Claimant is 18 or older) Date Varsity Sport of Student: _______________________________________ In order to assist in paying for medical bills due to injury, Eureka College offers a SECONDARY insurance through First Agency of Kalamazoo, MI. An extra premium is paid by the athlete, which varies by sport, before being eligible for participation. Eureka College is not legally liable for injuries, and will not pay for medical bills due to injury or illness. I, as an athlete, realize participation in athletics involves the potential for injury, which is inherent in all sports. I acknowledge that even with the best coaching, use of the most advanced protective equipment, and strict observance of the rules, injuries are still a possibility. On rare occasions, these injuries can be so severe as to result in total disability, paralysis, or death. In case of injury, this person may be reached: Name:________________________________________________________________________________________ Relationship:__________________________________________________________________ Phone #: ( _____ ) _______ - __________ I hereby give authorization to the athletic trainer and team physicians to evaluate and treat any injuries that occur during athletic participation at Eureka College. I understand the team physicians and Head Athletic Trainer have the authority to eliminate me from further participation due an injury, illness, and/or any undue risk to the college. Signature of Athlete:______________________________________________________________________________ Signature of Parent (if under 18 years):________________________________________________________________ Randy Henkels, Head Athletic Trainer, Eureka College, 300 E College Avenue, Eureka, IL 61530

We are extremely pleased to have your son/daughter as a student athlete at Eureka College and hope that he/ she will achieve academic, social, and athletic success. Each student athlete is required to have a physical examination completed within 6 months of first practice and prior to any participation in any intercollegiate sport. The final decision on physical qualifications or reasons for rejection is the responsibility of the team physician. The team physician and certified athletic trainers will determine when an athlete may return to competition after an injury.

studentathletes

Dear Parents of Eureka College Intercollegiate Athletes,

Injuries â&#x20AC;&#x201C; Medical Bills â&#x20AC;&#x201C; Insurance Coverage â&#x20AC;&#x201C; Claim Procedure Accidents do occur and we attempt to provide our athletes with the very best possible care. Medical bills may be incurred when the athlete is treated for bodily injury due to an accident, whether it occurs locally or during a road trip, by a medical vendor of his/her choice. The NCAA states there are no waivers for college athletic insurance coverage. One Firm Statement:

The NCAA discourages any college or university from providing coverage or paying the bills incurred for expenses related to illnesses or conditions which are not sustained as the direct result of an accident in our intercollegiate sports program (this includes pre-existing conditions and non-athletic injuries).

Insurance Coverage:

The athletic accident insurance at Eureka College provides coverage for your son/daughter for accidents while participating in the play or official team practice of intercollegiate sports, including sponsored and authorized team travel. This insurance has a $250 deductible.

Claim Procedure:

All medical bills for your son/daughter incurred as a result of an accident in the intercollegiate sports program will be sent directly to your son/daughter or to your home address, unless the college has instructed the medical vendors otherwise. In some cases, the athletic department may get a copy of the bill, but in no case will the athletic department be the primary location for the incurred bill to be sent.

Submit the bills incurred to your family insurance plan first.

They will take one of the following two actions:

A. B.

Honor the claim and pay all or a portion of the bills incurred. Not honor the claim and send you a letter of denial. An example might be that your son/daughter is no longer a part of your group policy after attaining the age of twenty-six.

studentathletes

If there remains a balance after your family insurance plan has contributed towards the claim, send the claim sheet from your insurance company and a copy of the itemized bills incurred to Eureka College’s Assistant Athletic Trainer, Sara Eggleston.

If you receive a letter of denial from your family insurance plan administrator, please send a copy of the letter of denial along with a copy of the bills incurred to Eureka College’s Assistant Athletic Trainer. If no coverage is available, a letter from your employer with verification will be necessary.

3. If the bills incurred are not acted upon by the family insurance plan (i.e. not large enough), the claim will be sent from the athletic department to our insurance carrier office which is in Kalamazoo, Michigan for processing. If they need any additional information, please cooperate with them and they will process the claim in the least possible amount of time. It is in your best interest to have the claim settled promptly since all the bills incurred are in your name. Please note:

If the primary family coverage is through an HMO or PPO, you must follow the proper procedures required by your plan in order for the college’s insurance to satisfactorily complete its portion of the claim. This is especially important if your plan requires pre-authorization to have your son/daughter treated if they are out of your plan’s service area. It is recommended that you become informed of local providers in Eureka, IL and the surrounding area whom are in network should your son/daughter require further evaluation and care.

Parents should retain this letter for future reference. Your cooperation in this important area will help make this program successful in minimizing delays and accomplishing the purpose for which it is intended.

EUREKA COLLEGE INSURANCE PARTICULARS: All athletes will have a $250.00 deductible. This may be met through payments by family insurance.

Guarantee Trust Life

250 - $15,000

Guarantee Trust Life

1 Year Benefit Period

15,000 - 90,000

4 Year Benefit Period

NCAA Lifetime Catastrophic Medical Coverage If you have any questions, please contact: Randy Henkels M.ED, ATC/L Head Athletic Trainer 300 East College Avenue Eureka, IL 61530 O:309-467-6378 F:309-467-6402

Sara Eggleston MS, ATC/L Asst. Athletic Trainer 300 East College Avenue Eureka, IL 61530 O: 309-467-6582 F: 309-467-6402

FOR STUDENT-ATHLETES ONLY • ATHLETIC INFORMATION SHEET PLEASE PRINT

Name ___________________________________________________________________________________ Sport(s) __________________________________________________________________________________ How many years participated at College Level _________________________ Home Phone Number __________________________________________ Home Address ____________________________________________________________________________ City ___________________________________________ State __________________ ZIP _____________ High School Attended ______________________________________________ Year in College _____________ Height ________ Weight ________ Position ____________________________________________________ Transfer Student? _________ Years Attended __________

studentathletesinfo

This sheet must be turned into the Athletic Office as soon as possible.

If So, Where? ___________________________________ Degree(s) Earned ___________________________ PARENTS INFORMATION: Father’s Name _____________________________________________________________________________ Address __________________________________________________________________________________ City ___________________________________________ State __________________ ZIP _____________ Phone(s) __________________________________________ Mother’s Name ____________________________________________________________________________ If different: Address __________________________________________________________________________________ City ___________________________________________ State __________________ ZIP _____________ Phone(s) _________________________________________________________________________________ HOMETOWN NEWSPAPER: Please list at least the Area Code of the newspaper. Name ___________________________________________________________________________________ Address __________________________________________________________________________________ City ___________________________________________ State __________________ ZIP _____________ Phone _______________________________________ Fax ________________________________________

ALL PLAYERS, NEW AND RETURNING, MUST FILL OUT THIS FORM!

connect Visit the campus intranet site, EC Connect, and discover how our campus communicates internally. • Join Your Eureka College Campus Community On-Line. • Learn the latest campus announcements via The Red Devil Daily. • Watch informative, and sometimes humorous, campus videos on EC Tube. • Receive the latest campus alerts and class cancellations. • Experience firsthand EC community internal campus communication avenues. • Find out what’s cooking in the Commons. • Find almost any campus form and schedule that exists.

Questions? Having challenges logging in? Lost in the site? Contact Cindy Lorimor, Coordinator of Web Services 309.467-6746 • clorimor@eureka.edu

on campus - ww2.eureka.edu off campus - http://ww11.eureka.edu:2164 If the server turns up an error message the alternate address is - http://192.168.10.15. Log in as “Student”, “Faculty”, or “Staff” and use your network login and password. Some links pull up an additional password request. These are protected for staff and faculty use only.

ww2.eureka.edu or 192.168.10.15 (backup) 22

Name ________________________________________________

Male

Female Age _________

Date of Birth ______ / ______ / _____ Parent/Guardian ______________________________ Home Phone ______________________________ Home Address _________________________________________________________________________ Sport(s) ______________________________________________________________________________ Please explain any YES answers at the bottom of the page: Have you had a medical illness or injury since your last check-up or sports physical?

Yes

Do you have a chronic or ongoing illness? Do you have a chronic or persistent cough? Have you ever had surgery? Are you presently taking any prescription or non-prescription drugs including an inhaler? Do you have any allergies? (Insect stings, foods, medicines) Have you ever had a rash or hives develop after exercise? Have you ever passed out during exercise? Have you ever had chest pains during exercise? Have you ever had shortness of breath after mild exertion? Have you ever felt dizzy during or immediately following exercise? Have you ever had high blood pressure? Have you ever been told that you have a heart murmur? Do you have a history of heart disease in your family? Has your doctor restricted you from sports because of heart problems? Have you ever had mononucleosis, myocarditis, or other severe viral infections? Do you have diabetes? Do you have hepatitis? Do you have anemia? Do you have asthma? Do you have epilepsy or convulsions? Do you currently have skin problems? Have you ever had a concussion? Have you ever had a head injury in which x-rays were required? Have you ever had a seizure? Do you have frequent or severe headaches? Have you ever had numbness or tingling in your arms, legs, hands, or feet? Have you ever had heat exhaustion or heat stroke? Do you wear a corrective or support brace during competition? Do you wear glasses, contact lenses, or protective eyewear during competition? Do you wear a dental appliance during competition? Have a physical ever recommended that you do not participate in contact sports?

Have you ever injured: Head Neck Shoulder Ankle/Foot Back Forearm

Elbow Shin

Knee Calf

Hip

Wrist/Hand

athleticphysical

ATHLETIC PRE-PARTICIPATION PHYSICAL EVALUATION

Explain YES answers here: ________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE

Signature of Athlete _________________________________________ Date ______________________

athleticphysical

PHYSICAL EXAM Name __________________________________________________ Age____________ Date ________________ Height ___________ Weight ___________ Vision:

Right 20/_____

Left 20/______

MEDICAL

Blood Pressure ______ / ______ Heart Rate ______________ Corrected? NORMAL

Yes

Contacts

Glasses

ABNORMAL FINDINGS

Eyes/Ears/Nose/Throat Mouth and Teeth Lymph Nodes Heart Pulse Lungs Abdomen Skin Genitalia- Hernia (male) MUSCULOSKELETAL Neck Spine Shoulders Arms/Hands Hips Thighs Knees Ankles Feet Neuromuscular Physical Maturity (Tanner Stage)

Further Medical Evaluation Required:________________________________________________________________ Cleared to Participate

Not cleared to participate

Date __________

Phone _______________

Print Name ______________________________________ Signature ____________________________________

Name: ________________________________________________________________ Student Commuter _____ Resident _____ Faculty Staff

VEHICLE INFORMATION

VEHICLE REGISTERED TO:

License Plate #: ____________________

Name: ___________________________________

State: ______ Make: _______________

Address: __________________________________

Model: ___________________________

City: _____________________________________

Year: __________ Color: ____________

State: ______________ ZIP: _________________

parkingregistration

PERSONAL INFORMATION

Signature: _____________________________________________________ Date: _________________________________________

SPS OFFICE USE ONLY PERMIT INFORMATION

REPLACEMENT INFORMATION

Parking Permit # : ____________________

Parking Permit # : _____________________

Date Issued: _______ / _______ / _______

Date Expired: _______ / _______ / _______

parking

Parking and Permit Information 2012-2013 Residential & Commuter Students Your permit will be valid for the entire school year and must be displayed inside of your car on your rearview mirror. The permit MUST be visible when you are on campus and can be switched to another car temporarily when/if needed. However, if you need to have another car on campus for more than a week at a time, you need to register your 2nd car with the SPS Office. Parking permit fees are included as part of your campus access fee. RESIDENTIAL STUDENTS: If you are a residential student, you have the ability to park in any “Residential

Student Lot” or “All Campus Lot”. (See diagram below.) Driving to class and/or parking in a “Commuter/ Faculty/Staff Lot” could result in you being ticketed. COMMUTER STUDENTS: If you are a commuter student, you have the ability to park in any “Commuter/

Faculty/Staff Lot” or “All Campus Lot”. (See diagram below.) Parking in a “Residential Student Lot” could result in you being ticketed. At no time should students give or sell their permit to another person or student to use. The permit must be used by the student who originally purchased the permit. If you have any questions, please stop by the SPS Office or call (309) 467-6420. More parking information can also be obtained from the Campus Traffic Rules and Regulations portion of the Student Handbook.

NOW ONLINE: www.eureka.edu

Book store the

of Eureka College

inside the Cerf Center

– Online Textbook Reservations – New & Used books – Book Buy-Back – Book Rental [eurekacollege.rentsbooks.com] – Eureka College Spirit Wear & Gifts – Monday - Friday 9am-3pm | 467.6426

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Office of Student Programs and Services 300 East College Avenue | Eureka, Illinois 61530-1500