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Page 1: GOPHER HOCKEY CHEERLEADING TEAM Try-out Packet 2019-2020 · The Gopher Hockey Cheerleaders perform on the ice before the game and between periods as well as in the stands during the

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GOPHER HOCKEY CHEERLEADING TEAM Try-out Packet 2019-2020

Page 2: GOPHER HOCKEY CHEERLEADING TEAM Try-out Packet 2019-2020 · The Gopher Hockey Cheerleaders perform on the ice before the game and between periods as well as in the stands during the

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2019-2020

TRYOUT PACKET University of Minnesota

HOCKEY CHEER

TRYOUT DATES/TIMES [NOTE: All practices are REQUIRED]:

Friday, April 26, 2019 5:00-5:30 PM Registration, Ridder Arena Lobby

5:30-5:45 PM Intro Meeting/Welcome

6:00-8:00 PM Ice Practice, Ridder Ice Arena

8:00-10:00 PM Cheer/Dance Clinic, Ridder Arena Lobby

Saturday, April 27, 2019 9:30-11:30 AM Open Ice Practice, Ridder Arena

11:45-1:45 PM Individually Scheduled Interviews, Ridder Arena Club Room/Suites

2:00-3:30 PM Land Practice (dance/cheers/fight songs), RidderArena Lobby

2:30-3:30 PM Dance Evaluations, Ridder Club Room

4:30-7:30 PM Final Try-out, Ridder Arena (closed to the public)

8:30 PM Team roster will be posted (outside Ridder Lobby)*Note: roster may be posted earlier

Sunday, April 28, 2019 9:30 AM-12:30 PM Official 2019-2020 Team Meeting

It is important that you read and fully understand the enclosed information.

Give serious thought to the level of commitment you must make if you are chosen

to be a part of this program.

If you have any questions or concerns, please do not hesitate to e-mail

Coach Anderson at [email protected].

Thank you for your interest and GOOD LUCK!

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Letter from the Head Coach

Dear Spirit Squad Prospect:

Becoming an athlete in the Spirit Squad program at the University of Minnesota, means becoming part of a rich

tradition and a legacy that started over 100 years ago. Cheerleading was invented in 1898 on the University of

Minnesota campus, and our founder’s spirit and pride continue today. Very few people have had the privilege of

participating in America’s ORIGINAL cheerleading program.

Within the last decade, our teams have had a variety of notable accomplishments. Goldy Gopher has won 4

Mascot National Championships, finished top 5 for the last 15 years, and twice named NCAA/ESPN Mascot of

the year. The Hockey Cheer Team is comprised of talented figure skaters and has been recognized on ESPN,

BTN, Sports Illustrated, USFS Skating Magazine and is among the top Hockey Cheerleading teams in the

country. The Co-ed Cheer Team has consistently placed among the top 10 teams in the country in one of the

most competitive divisions at UCA College Cheer Nationals and finished 2nd place in Game Day in 2018.

Additionally, the U of M’s All-Girl Cheer Team, over the last 10 years, has finished top 5 four times in the most

competitive division at UCA College Cheer Nationals and finished 2nd place in Game Day in 2019. The Dance

Team has won 19 National Championships and is by far the winningest athletic team on the U of M campus,

winning 11 Jazz titles and 8 Pom titles.

Along with this great history comes a very serious sense of responsibility. As a Spirit Squad athlete you are a

representative not only of the athletic teams and department you support at this University, but also the entire

State of Minnesota. You are the most visible ambassadors we have, and it is expected that you conduct yourself

accordingly on and off the playing field.

The Spirit Squad is comprised of 6 teams and over 100 dedicated student-athletes who devote 15-20 hours

weekly to practices, games, special appearances, camps/clinics, fundraising events, and competitions. Spirit

Squad athletes are also expected to maintain high academic standards and carry a full credit load. Because of

these responsibilities, we are looking for skilled and talented athletes, and well-rounded students, who embrace

the ability to be coached, as well as find a healthy balance between athletics, school, family, and friends.

Our athletes come from across the country and many from diverse backgrounds in dance, cheerleading,

gymnastics, and skating. The common-ground amongst all of our program athletes is their dedication and

commitment to this program. Our athletes believe that improving as individuals, helps their team improve as

well.

We are excited for your interest and believe that the rewards from this experience cannot be measured. Imagine

the excitement that comes with being part of a Big Ten athletic department, performing at some of the biggest,

nationally televised games, traveling to storied venues around the country, and competing against some of the

top cheerleading and dance programs in the nation. Every once in awhile you come across an opportunity and

make a decision that will change your life, securing friends for a lifetime and your place in history forever.

Sincerely,

Coach Owens, Head Spirit Squad Coach

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DESCRIPTION/COMMITMENT

The Gopher Hockey Cheerleaders combine choreographed individual figure skating skills, synchronized skating skills, dancing, and cheerleading on the ice and in the stands, into one unified sport. Furthermore, the team at the University of Minnesota is looked upon as an especially unique and innovative representative within the sport of hockey cheerleading, given that all of the girls on the team are talented figure skaters.

The Gopher Hockey Cheerleaders perform on the ice before the game and between periods as well as in the stands during the game. Their time is dedicated to performing, supporting the hockey team, and adding to the Gopher fan experience.

As members of the Minnesota Hockey and Spirit Squad families, Gopher Hockey Cheerleaders participate because they love the sport of hockey, love figure skating, want to continue performing in college, and take pride in being part of this great Minnesota tradition.

HOCKEY CHEER TEAM This unique team cheers and performs on the ice and in the stands at all home hockey games. They will make special

appearances on occasion, and put in approximately 10-20 hours per week. They cheer for the legendary Golden Gopher

men’s hockey team at 3M Arena @ Mariucci. The team consists of 10-12 female members, and all hockey cheerleaders

are required to have a vast array of figure skating skills, as they perform on the ice between periods.

Time Commitment:

Summer Practices (all dates tentative, exact dates TBA)

Twins Games (Hockey Cheer/Mascots) May 24, 25, 26, and July 19, 20, 21

Mandatory Spirit Squad Retreat: July 12-14, 2019

Report Date: August 5

Mandatory Off-ice Practice (Cheer): Aug. 5-9 (evenings)

Mandatory Team Practice: Aug. 12-16, Aug. 19-23 (evenings)

School Year Practices YOU MUST SCHEDULE CLASSES AROUND PRACTICE/GAMES Start the first week of school – Tues, Sept. 3, 2019

Practice: Three evenings per week 4:00-6:00pm Tuesdays, Wednesdays, and Thursdays

Required Strength and Conditioning: 2 (1-hour) sessions per week: 6:00-7:00am Tu, Th

Skating Open Ice – Hockey Cheer Team Only, 1 evening/week based on team availability (usually

Monday) Gopher Men’s Hockey Season runs from October-April games are typically on Fridays and Saturdays (5:00-10:00pm)

Special Events/Appearances You may be required to attend events sponsored by the athletic department

Hockey cheerleaders work at all U of M Spirit Squad fundraisers

Team activities do not stop during the Holiday season or Spring Break

Expenses: (team members are able to keep whatever items they are required to purchase)

Team Fee $350 (Includes items such as briefs, poms, body suits/uniform pieces, etc.)

Required Fundraising in the summer (Twins Games)

The team may also purchase jackets, bags, sweatshirts and T-shirts on their own (not required)

In the event you do not choose to honor your commitment and finish the season or you are dismissed from

the program, you will be required to reimburse the U of M for payments made on your behalf

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TRYOUT REQUIRMENTS

ELIGIBILITY: Spring tryouts are open to individuals who have been accepted by the University of Minnesota, Twin Cities for Fall Semester 2019.

All participants, including transfer students and current team members, must have a minimum 2.0 GPA and have graduated from high

school. Incoming students must bring a copy of their letter of acceptance on the first day of tryouts. Current U of M students must

bring an unofficial transcript.

SKILLS: Suggestions: All hockey cheerleaders are suggested to have passed or be at the level of United States Figure Skating: Junior/Senior

Freestyle (test track) or Juv/Intermediate Free (IJS) and Junior/Senior Moves in the Field; ISI Freestyle 8 or above. Synchronized

skating experience is helpful, but not required. No previous cheer or dance experience required.

Except for the dance, the tryout will take place entirely on the ice. Here is an outline of how the tryout will run:

1. DANCE (only element performed off-ice):

You will perform a dance that will be taught to you at tryouts. The dance will be the only element performed on dry land; the rest of

the tryout will be on ice.

2. ON-ICE ENTRANCE:

During your entrance, you will demonstrate figure skating skills as music to “Minnesota March” plays. The following REQUIRED

SKATING SKILLS must be performed during the music segment:

Axel (single or double; must be fully rotated)

Double Jump: Salchow, Loop, or Axel (choose one) *Note: if you choose double axel, you do not need to repeat the skill

Flying Camel/Sit Combo Spin – variations allowed within these basic positions

Layback Spin

Split or stag falling leaf

Heel Stretch Right OR Left leg (either forward or backward) – may be done gliding or while spinning

Bauer or Spread Eagle (R or L)

Step Sequence (using approx. ½ ice – should include skills such as Brackets, Rockers, Choctaws, Counters, Loops, Twizzles)

*NOTE: each spin must consist of 4 complete revolutions in the specified spin position

3. FIGHT SONG MOTIONS:

During “Minnesota March” you will stop at center ice and perform the cheerleading motions that go along with that portion of the

song (taught at try-outs). Music will continue and you can perform more required skating skills until the song ends.

4. CHEER:

You will shout the words and perform motions to 1 cheer, taught at tryouts.

5. SKATING PROGRAM:

You will provide your own program music (on iPod/phone); bring a past skating program or a routine that you choreographed to your

favorite song (something that shows your ice presence/personality is preferred). You will use the music to demonstrate additional

figure skating skills. Extra emphasis should be placed on performance choreography, show skills (i.e. unique spin variations,

flexibility/balance skills, big/exciting jumps, intricate/unique footwork, flying spins/death drop/butterfly), attire, and over-all appeal –

use your program to tell us more about you as a performer. There is no required time length – give yourself enough time to show your

talent/skills, but not too much time where you lose the effect of the mood/choreography.

TRYOUT PROCESS: Throughout the couple of days of clinics and the final tryout you will be observed by the U of M Coaching Staff as well as a selection

committee. There may be a tryout cut at any time during the clinics. The final decisions are made by the coaching staff.

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UNIVERSITY OF MINNESOTA INFORMATION

FIGHT SONG: “MINNESOTA MARCH”:

Rah! Rah! Ski-U-Mah. Rah! Rah! Rah!

March on, March on to Victory.

Loyal Sons of the Varsity.

Fight on, Fight on for Minnesota

For the glory of the Old Maroon and Gold (2, 3)

March on, March on to win the game.

Down the ICE, fighting every play.

We're with you, team, Fighting team!

Hear our song, we cheer along

To help us win a victory.

Page 7: GOPHER HOCKEY CHEERLEADING TEAM Try-out Packet 2019-2020 · The Gopher Hockey Cheerleaders perform on the ice before the game and between periods as well as in the stands during the

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APPLICATION CHECKLIST

The following is a checklist to help ensure you are prepared for tryouts. Please follow these instructions

carefully and bring your completed packet/application with you to tryouts. If you have questions, please contact

Coach Anderson at least a week before try-outs ([email protected]).

IT IS ESSENTIAL THAT YOU HAVE ALL ITEMS ON THIS LIST

TO TURN IN AT REGISTRATION. You will not be able to

participate in any portion of the tryout process without complete

forms (including any missing information on the forms) - this includes

veteran/returning members.

1. Application/ Picture (attached)

a. All applicants must complete form on p. 8 and corresponding questionnaire.

b. Please attach a current photo.

2. Try-out Fee: $40 cash or check made out to University of Minnesota

3. Waiver Form (attached)

a. All applicants must complete and sign the Waiver Form – no substitutions.

b. If you are under the age of 18, you must have a guardian’s signature.

4. Demographic/Insurance Form (attached)

a. All applicants must complete both pages of the Medical Insurance Form.

b. Attached to this form, all applicants must provide a photocopy of the front and back of

your medical insurance card.

c. Be sure to complete the form in full – i.e. Policy Holder Information, DOB, etc. and it must

be signed.

d. Must complete the U of M Insurance Form – no substitutions will be accepted.

5. Pre-Participation Physical/Heath History Form (attached)

a. New candidates only.

b. Must be completed within the past 6 months (from tryout date).

c. Must indicated or be marked “Cleared” for participation.

d. If applicant is under the age of 18, it must co-signed by a guardian.

6. Sickle Cell Trait Testing Waiver (attached)

a. New candidates only.

7. Health Service To Minors Form (attached)

a. New candidates (under age 18) only.

8. Proof of Admission

a. Copy of acceptance letter for incoming freshmen/transfer students

b. Unofficial copy of transcript for current University of Minnesota students

c. New candidates only.

Page 8: GOPHER HOCKEY CHEERLEADING TEAM Try-out Packet 2019-2020 · The Gopher Hockey Cheerleaders perform on the ice before the game and between periods as well as in the stands during the

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2019-2020 SPIRIT SQUAD APPLICATION

Hockey Cheerleading Team

PERSONAL INFORMATION:

Name: (last) (first) (middle)

Current Address:

(street)

(city) (state) (zip)

Current Phone:

Your Email address:

Parents Name(s):

(First) (Last) / (First) (Last)

Parent # 1Address:

(Street)

(City) (State) (Zip Code)

Parent #1 Phone:

Parent # 2 Name: (If different from above) (First) (Last)

Parent # 2 Address:

(If different from above) (Street)

(City) (State) (Zip Code)

Parent #2 Phone:

High School Name:

School year:

Fr So Jr Sr 5th Year Major:

Will you have any conflicts over the summer? (please specify dates)

Student Identification Number:

University of Minnesota x500 (e-mail):

Birth Date:

Are you currently employed? If yes, where?

Will you be working while you are in school?

If yes, how many hours per week?

Please attach

current photo

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2019-2020 SPIRIT SQUAD QUESTIONNNAIRE FOR PROSPECTIVE (NEW) ATHLETES

1. What high school sports were you involved in, if any?

2. What other extra-curricular activities did you participate in?

3. Please explain any volunteer/community service activities:

4. If you have it, please tell us about your cheerleading/dance experience:

5. Please tell us about your skating experience:

6. Describe yourself, your interests, and pastimes (attach additional page if necessary):

7. Why are you interested in becoming a member of the University of Minnesota Spirit Squad [Hockey Cheerleading]

program? (attach additional page if necessary):

Page 10: GOPHER HOCKEY CHEERLEADING TEAM Try-out Packet 2019-2020 · The Gopher Hockey Cheerleaders perform on the ice before the game and between periods as well as in the stands during the

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2019-2020 SPIRIT SQUAD QUESTIONNNAIRE FOR RETURNING ATHETES

1. What qualities do you possess that bring value to the team?

2. What role do you hope to play this upcoming season on the team?

3. What qualities do you look for in a good team captain/leader? Give 2-3 specific examples.

4. As you know, there is a fair amount of independent skill-work and conditioning that you’re accountable for during

the season, how do you plan to set and achieve goals independently throughout the season? (Please list and explain 2-3

specific examples)

5. How has being a athlete on the Hockey Cheerleading Team enhanced your life?

6. What is your preferred learning style? (i.e. visual, aural, physical, verbal, logical, solitary, social)

7. Why are you interested in returning as an athlete of the University of Minnesota Spirit Squad [Hockey Cheerleading]

program? (attach additional page if necessary)

Page 11: GOPHER HOCKEY CHEERLEADING TEAM Try-out Packet 2019-2020 · The Gopher Hockey Cheerleaders perform on the ice before the game and between periods as well as in the stands during the

UNIVERSITY OF MINNESOTA ATHLETIC MEDICINE TRY OUT WAIVER

To be eligible to participate in an Intercollegiate Athletics Try-Out participants must:

Provide medical documentation of an athletic pre-participation history & physical, signed by a medical doctor (either an MD or a DO) and dated within six months of the start of this team tryout.

Provide confirmation of sickle cell trait (SCT) status, either through: 1) existing documentation from birth, or; 2) recent screening. Or the student may sign a waiver declining confirmation of SCT status if he or she is first provided education by the institution regarding the implications of exercising the waiver option.

Complete the Demographic and Insurance Information sheet and provide proof of current medical insurance with a copy of the front and back of current insurance card. If participant makes the spirit squad team, usable insurance in the state of Minnesota (which covers athletic-related and specifically cheer-related injuries) will be required prior to starting any team related activity.

I acknowledge my voluntary participation in practice activities associated with the SPIRIT SQUADS at the University of Minnesota. This try-out will extend no longer than 4 days.

I understand that while I am participating in intercollegiate athletics there is a risk of injury. I understand that such an injury can range from a minor injury to a major injury. Such injuries could cause permanent disability such as paralysis, permanent bone or joint injury, permanent scars, other chronic disabling conditions and even death.

I hereby waive any and all claims, causes of action, rights to entitlements, suits or damages against the University of Minnesota, the Intercollegiate Athletic Department, or any of its employees, agents or representatives, as a result of or occurring in conjunction with, my participation during this try-out. I also waive any and all claims to any other services, uniforms, equipment, medical or training services, academic services, tutoring, computers and the like.

I verify that I have no physical disabilities, impairments or chemical dependencies that inhibit my participation in sport activities. I do not know of any medical reason why I should not participate in a try-out for my sport. I hereby accept and assume the risk of injury and understand the possible consequences of such injury.

I, the undersigned, have read this form carefully and understand all its items.

Participant Signature Date

Printed Name of Participant Date of Birth

Student ID Number

Parent/Guardian Signature (if a minor) Date

MDN 3-23-16

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Office Use Only: Medical Record Number:

2018-2019

Master EMR

UNIVERSITY OF MINNESOTA ATHLETIC MEDICINE Demographic/Insurance Information

Student-Athlete’s Name M or F

Circle one

Date of Birth

Student ID Sport

Please use black ink only. Provide all information to avoid a delay in participation.

Ca

mp

us

Campus Mailing Address

Cell Phone # ( )

UMN Email address @umn.edu

Em

erg

en

cy

Co

nta

ct

Emergency Contact Name

Relationship to Student-Athlete

Street Address, City, State, Zip

Phone Numbers/ Email address

Telephone ( )

Cell Phone ( )

Email Address

Pri

ma

ry I

nsu

ran

ce

My son/daughter will NOT have medical insurance and will therefore be purchasing the Student Health Benefit Plan

My son/daughter will be covered under the following health plan (please provide the following information):

Insurance Company ID Number Group Number

Insurance Company Mailing Address

Phone Number ( )

Effective Date Deductible Amount

Subscriber Name Subscriber Date of Birth Subscriber Employer

Health Savings Account Yes No

HSA Acct Number Owner’s Name HSA Amount

Se

co

nd

ary

Ins

ura

nce

Insurance Company ID Number Group Number

Mailing Address

Phone Numbers ( )

Effective Date Deductible Amount

Subscriber Name Subscriber Date of Birth Subscriber Employer

Ph

arm

ac

y I

ns

ura

nc

e

Company Name

Den

tal

Ins

ura

nce

Company Name

ID Number

ID Number Group Number

BIN # PCN Mailing Address

Group Number City, State and Zip

Phone Number ( )

Phone Number ( )

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Page 2 of 3

Pri

ma

ry C

are

/

Ne

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Please provide contact information for your Primary Care Provider (PCP). Also review the health plan policy regarding HMOs/PPOs and the options for changing your primary clinic.

PCP Name

Address City, State, Zip Phone Number ( )

The primary insurance plan is a HMO or PPO policy If the insurance plan is a PPO policy, please provide the name of the network that can be used in Minnesota:

Copies of medical, dental and pharmacy insurance cards (front and back)

I certify that the above information is true and correct. If incorrect or incomplete information is given, I may be responsible for all charges. I understand that I am responsible for payment of all charges incurred for claims classified as “non-athletic”. I understand that I must forward changes of insurance and information to the Athletic Medicine Department as they occur through the year.

By signing below, I grant the Insurance Coordinator in Intercollegiate Athletics at the University of Minnesota, access to my medical records and insurance information in order to coordinate benefits, make inquiries and make payments on my behalf. This permission is granted for one year and may be revoked, in writing, at any time.

Policy Holder’s Signature Date Student-Athlete Signature Date

Page 14: GOPHER HOCKEY CHEERLEADING TEAM Try-out Packet 2019-2020 · The Gopher Hockey Cheerleaders perform on the ice before the game and between periods as well as in the stands during the

Office Use Only: Medical Record Number:

2018-2019

Master EMR

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UNIVERSITY OF MINNESOTA ATHLETIC MEDICINE

Sickle Cell Trait Testing Waiver

Patient label

About Sickle Cell Trait

Sickle cell trait is an inherited condition of the oxygen-carrying protein, hemoglobin, in the red blood cells.

Sickle cell trait affects approximately 1% of the U.S. population (approximately 1 in 100 individuals).

Although Sickle cell trait is most predominant in African-Americans and those of Mediterranean, Middle Eastern, Indian, Caribbean, and South and Central American ancestry, persons of all races and ancestry may test positive for sickle cell trait.

Sickle cell trait is usually benign, but during intense, sustained exercise, hypoxia (lack of oxygen) in the muscles may cause sickling of the red blood cells (red blood cells changing from a normal disc shape to a crescent or “sickle” shape), which can accumulate in the bloodstream and “logjam” blood vessels, leading to collapse from the rapid breakdown of muscles starved of blood.

Sickle Cell Trait Testing The NCAA mandates that medical examinations for athletic participation include sickle cell trait testing to ensure that all NCAA student-

athletes have knowledge of their sickle cell trait status before the student-athlete participates in any intercollegiate athletics event, including strength and conditioning sessions, practices, competitions, etc. Sickle cell trait testing is not required by NCAA when a student-athlete provides documented prior results to the institution or knowingly and voluntarily declines testing and signs a written release.

The University of Minnesota Department of Intercollegiate Athletics offers sickle cell trait screening in the form of a blood test to all student-athletes as part of the pre-participation physical examination process.

Testing will be conducted at the University of Minnesota Physicians Laboratory and the results will be reported to a University of Minnesota Team Physician.

SICKLE CELL TRAIT TESTING WAIVER I, __________________________________, understand and acknowledge that the NCAA and the University of Minnesota Department of Intercollegiate Athletics require medical examinations that include sickle cell trait testing so that all student-athletes have knowledge of their sickle cell trait status. Additionally, I have read and fully understand the aforementioned facts about sickle cell trait and sickle cell trait testing.

Recognizing that my true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries, ailments, and/or disabilities experienced, I hereby affirm that I have fully disclosed in writing any prior medical history and/or knowledge of sickle cell trait status to University of Minnesota the Athletic Medicine staff.

Understanding the risks of sickle cell trait and athletic participation, I do not wish to undergo sickle cell trait testing as part of my pre-participation physical examination, and I voluntarily agree to release, discharge, indemnify and hold harmless the Regents of the University of Minnesota, its officers, employees and agents from any and all costs, liabilities, expenses, claims, demands, or causes of action on account of any loss or personal injury that might result from my declining sickle cell trait testing.

I have read and signed this document with full knowledge of its significance. I further state that I am at least 18 years of age and competent to sign this waiver.

Student-Athlete Signature Date Sport

Student-Athlete Print Name UM ID#

Parent / Guardian Signature (if under 18 years of age)

Date

Witness Date

UM Athletic Medicine / OGC June 2013

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UNIVERSITY OF MINNESOTA ATHLETIC MEDICINE

Health Services To Minors

University of Minnesota Athletic Medicine complies with the laws of the State of Minnesota when providing health

services to minors (persons under age 18). Under the following circumstances you may give consent for yourself to

receive medical, dental, mental, or other health services:

If you are emancipated, i.e., living away from parents or legal guardian and managing your own finances,

regardless of income source;

If you are married or have given birth to a child; or

If you require services relative to pregnancy, sexually transmitted disease, or chemical dependency.

Minors, not meeting the above criteria, need to have parental/guardian authorization for health services except when

emergency care is required, i.e., the risk to life or health is of such a nature that treatment should be given without

delay, and the requirement of consent would result in delay or denial of treatment.

By giving your consent for any of the foregoing medical, dental, mental, or other health services, you assume financial

responsibility for the cost of these services.

University of Minnesota Athletic Medicine staff may inform you parents or legal guardian of treatment provided or

care needed where, in the professional's judgment, failure to inform your parents or guardian would seriously

jeopardize your health.

PARENTAL/GUARDIAN AUTHORIZATION FOR TREATMENT OF MINORS (Persons under age 18)

I authorize that in the event of an illness or injury, medical or hospital care by provided to

Participant’s Name (please print) Date of Birth

I further authorize each of the following:

A. I grant permission to the University of Minnesota Athletic Medicine staff member to employ such diagnostic

procedures and medical treatment as deemed necessary.

B. I authorize the University of Minnesota Athletic Medicine Staff, University of Minnesota Physicians Clinics,

Hospital or other medical care units to release medical records information to the appropriate health insurance carrier in

order to process claims.

I understand that I am financially responsible for charges not covered or paid by student fees or insurance and hereby

guarantee full payment to the physicians or health care units.

Participant’s Signature Date Team

Participant’s Print Name UM ID#

Parent / Guardian Signature (if under 18 years of age)

Date

Parent / Guardian Print Name Date Witness Date