CONTRA COSTA COLLEGE

I hereby authorize the Certified Athletic Trainer(s) and Sports Medicine Staff (and when traveling to away games/events, I authorize the hosting team's Athletic Trainer(s) and Staff) acting on behalf of Contra Costa Community College to evaluate and treat any injury or illness that occurs as a result of my participation in intercollegiate athletics and/or during my time as a student-athlete at Contra Costa Community College. This includes any and all reasonable and necessary preventive care, emergency care, treatment, and rehabilitation for any injuries or illnesses.

I understand that I must refrain from practice while injured or ill. When under medical care, I may not return to participation until I have been given permission by the Team Physician, his/her delegate, or Certified Athletic Trainer. The Athletic Trainer at Contra Costa Community College has the FINAL authority regarding participation status. This authorization expires two (2) years from the date signed.

I hereby waive all claims against the Contra Costa Community College District for any care and treatment that I receive, or for the decision to provide care or treatment, or the decision not to do so. I agree to reimburse the District for any costs and expenses it incurs for any medical care or treatment provided.

I ACKNOWLEDGE THAT I HAVE HAD SUFFICIENT OPPORTUNITY TO REVIEW THE PROVISIONS OF THE WAIVER AND RELEASE, INCLUDING POSSIBLE REVIEW BY AN ATTORNEY, AND UNDERSTAND ITS PURPOSE, MEANING AND INTENT, AND THAT IT CONSTITUTES A WAIVER OF RIGHTS AND LIABILITIES.

The undersigned understands that participation in intercollegiate sports and/or any physical activity at Contra Costa Community College, by its nature poses inherent dangers of serious personal injury. No amount of care, caution, training, coaching, instruction, conditioning, supervision, or expertise can eliminate these risks. These injuries could include, but are not limited to:

• Sprains/Strains • Disfigurement • Cuts/Abrasions
• Head/Brain Injuries • Unconsciousness • Loss of Eyesight/Hearing
• Paralysis/Disability • Fractured Bones/Dental Damages • Communicable Diseases
• Dehydration • Back and Neck Injuries • Death/Death to Unborn Children

ALL PARTICIPANTS SHOULD UNDERSTAND THAT THEIR PARTICIPATION IS VOLUNTARY AND IS NOT REQUIRED BY THE COLLEGE DISTRICT.

The undersigned hereby forever releases, discharges, agrees not to sue, and holds harmless the Contra Costa Community College District, its employees, governing board members, officers, agents, representatives, coaches, instructors, volunteers, referees, sponsors, and any other persons affiliated with Contra Costa Community College from any and all liabilities, claims, demands, suits, actions, or losses of any kind for PERSONAL INJURY, DISABILITY, DISFIGUREMENT, PARALYSIS, AND ANY OTHER LOSSES OR DAMAGES TO PERSON OR PROPERTY, INCLUDING DEATH, arising out of participation in ANY and ALL intercollegiate sports/classes/activities, HOWEVER CAUSED, EVEN IF CAUSED BY THE PASSIVE OR ACTIVE NEGLIGENCE OF THE RELEASEES, TO THE FULLEST EXTENT OF THE LAW.

I ACKNOWLEDGE THAT I HAVE HAD SUFFICIENT OPPORTUNITY TO REVIEW THE PROVISIONS OF THE WAIVER AND RELEASE, INCLUDING POSSIBLE REVIEW BY AN ATTORNEY, AND UNDERSTAND ITS PURPOSE, MEANING AND INTENT, AND THAT IT CONSTITUTES A WAIVER OF RIGHTS AND LIABILITIES.

I hereby authorize the Contra Costa Athletic Trainer, Sports Medicine Staff, and their agents or consultants to perform diagnostic and treatment procedures that, in their judgment, may become necessary while I am at Contra Costa Community College.

I give permission for an ongoing exchange between my healthcare provider of my choice, the team physician, and the Contra Costa Sports Medicine, Athletics Department, and Athletic Trainer of all records that may pertain to Athletics clearance, illnesses and/or injuries, and health records as needed for academic accommodation and injury management/care. This disclosure can be used for: Medical Treatment, Medical Condition Verification, Billing, Legal, and/or Insurance.

Do not release any sensitive information related to AIDS and/or HIV infection. I understand that this authorization may be revoked in writing at any time.

I ACKNOWLEDGE THAT I HAVE HAD SUFFICIENT OPPORTUNITY TO REVIEW THE PROVISIONS OF THE WAIVER AND RELEASE, INCLUDING POSSIBLE REVIEW BY AN ATTORNEY, AND UNDERSTAND ITS PURPOSE, MEANING AND INTENT, AND THAT IT CONSTITUTES A WAIVER OF RIGHTS AND LIABILITIES.

The Athletic Department at Contra Costa Community College WILL NOT be responsible for any pre-existing injury or any operations not covered by our insurance. Medical expenses due to illness ARE NOT covered by the Contra Costa College Athletic Insurance Policy. In order for all athletes to receive complete medical benefits: (1) Upon receiving ANY injury during a practice or game, the athlete MUST REPORT IMMEDIATELY to the Certified Athletic Trainer or Physician. (2) If emergency treatment is required while away from campus, it is the responsibility of the coach to contact the host school's Certified Athletic Trainer. (3) Referrals to the team physician can only be made by the Certified Athletic Trainer. (4) Please provide a photocopy of the front and back of your medical insurance card.

The college provides "excess" or "secondary" insurance — coverage goes into effect only after ALL other insurance has been exhausted. The policy covers up to $25,000 maximum. Injuries must be treated within 120 days from date of injury. Coverage extends up to 365 days from date of injury.

Football, Soccer, and Wrestling: $100.00 deductible per injury. All other sports: $50.00 deductible per injury.

Benefits NOT provided for: orthopedic appliances (unless prescribed), pre-existing conditions, injuries during transportation (except school vehicle), orthodontics. INSURANCE COMPANIES DO NOT ALWAYS PAY ALL BILLS — YOU AS THE PATIENT ARE RESPONSIBLE FOR ALL BILLS INCURRED.

This consent form authorizes the Contra Costa College (CCC) Athletic Training Department to utilize Healthy Roster — a secure, HIPAA and FERPA-compliant software platform — for recording, storing, and communicating athlete injury and medical information. By signing this form, the athlete (and a parent/guardian if the athlete is a minor) gives permission for CCC athletic trainers to manage the athlete's medical records and coordinate care through Healthy Roster.

Contact information provided will be used solely for medical communication, injury/rehabilitation updates, and setting up the Healthy Roster account — never shared for unrelated purposes. Personal health information will be kept confidential in compliance with HIPAA and FERPA, accessible only to authorized personnel. I may revoke this authorization at any time by providing written notice to the CCC Athletic Training Department.