NEWPACKETSTUDENT

welcome

2012-13 academic calendar

important contacts

personal data

immunizations

student athletes information

parking registration

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general information

checklist

health questionnaire insurance verification

athletic physical

parking & maps

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!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 pro-cess 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 CampbellDean of Students

 

AUGUST

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

JANUARY

MARCH

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Residence Hall Move-InAugust 18

Welcome WeekAugust 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.

HomecomingOctober 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.”

GraduationMay 10 – 11

Baccalaureate is on Friday, May 10, 2013.

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

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.

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AUGUST

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

JANUARY

MARCH

APRIL

MAY

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August 1818-2122

September 3

October 1-5622-23

November 2021 2526

December 67, 8,10,11 11

January 13131421

March 89-17171829

April 1221

May 2 3, 4, 6, 7

Residence Halls OpenWelcome Week

Classes Begin (Semester 1)

No Classes (Labor Day)

Homecoming WeekHomecoming Game

Fall Break

Residence Halls Close 5pmThanksgiving Break BeginsResidence Halls Open 8am

Classes Resume

Study DayFinals for Semester 1

Residence Halls Close 5pm

New Student OrientationResidence Halls Open 8amClasses Begin (Semester 2)

No Classes, Martin Luther King Jr. Day

Residence Halls Close 5pm Spring Break

Residence Halls Open 8amClasses Resume

Easter Break

Easter Break Classes Resume

Honors Ceremony

Study Day Finals for Semester 2

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COMPUTERSAll 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 College’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 student’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 MAILEvery 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:

Student’s NameEureka College # (Campus Box Number)

300 E. College AvenueEureka, 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-MAILAdditionally, 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.

PARKINGStudents 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.

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HEALTH INFORMATIONAll 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 2012-2013 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.

TUITION MANAGEMENTAs a service, a student’s expenses may be spread over ten (10), nine (9), or eight (8) monthly payments, with-out 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.

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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 REQUIREMENTNCAA 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 = $275.00Basketball/Soccer = $165.00All 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 PROTECTIONIt 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.

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Academic Advising (309) 467-6302Registrar

Academic Concerns (309) 467-6301Provost

Athletics (309) 467-6377Athletic Director

Athletic Training (309) 467-6378Athletic Trainer

Billing Chief Financial Officer (309) 467-6305Student Accounts Manager (800) 548-9144

Bookstore (309) 467-6426Bookstore Manager

Business Office/Campus Work (309) 467-6312Human Resources

Career Planning & Internships (309) 467-6413Director of Career Services

Care Packages/Birthday Treats (309) 467-6413Student Foundation Advisor

Counseling (309) 467-6429Chaplain

Course Scheduling (309) 467-6303Registrar or Assistant Registrar

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

Business Office/Human Resources: (309) 467-6305 or 1-800-548-9144

Provost’s Office: (309) 467-6301

Financial Aid Office: (309) 467-6310

Records Office: (309) 467-6303

Student Programs and Services: (309) 467-6420

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

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

Health Services (309) 467-6420Dean of Students

General Information (309) 467-3721Switchboard

Housing/Residential Life (309) 467-6419Director of Residential Life

Information Technology (309) 467-6451

Learning Resource Center (309) 467-6592Director of Learning Center

Library Services (309) 467-6382Director of Melick Library

New Student Orientation (309) 467-6436Assistant Dean of First-year Programs

Religious Life (309) 467-6429Chaplain

Student Activities (309) 467-6407Director of Student Activities

Student Services (309) 467-6420Dean of Students

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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 physician’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 ServicesEureka College

300 E. College AvenueEureka, IL 61530-1500Phone: (309) 467-6420

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Return to:Student Programs and Services300 E. College Ave., Eureka, IL 61530-1500

Name ______________________________________________________________________________

Permanent Address ___________________________________________________________________

City ____________________________________ State __________________ ZIP ________________

Telephone ___________________________________ Cell ___________________________________

Email ______________________________________________________________________________

Hometown Newspaper ____________________________ Phone ______________________________

Fax ________________________________________________________________________________

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

Required if student is under the age of 21)FATHER

Name _____________________________________

Address:____________________________________

__________________________________________

(H) ______________________________________

(O) ______________________________________

MOTHER

Name _____________________________________

Address:____________________________________

__________________________________________

(H) ______________________________________

(O) ______________________________________

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

Financial Statement:

Father Only

Mother Only

Both Parents

Self

Other: ____________________________

Academic Report:

Father Only

Mother Only

Both Parents

Self

Other: ____________________________

___________________________________________________ ______________________________ Signature Date

– Continued on back –

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Mandatory Medical Information

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

Name

_______________________________

_______________________________

Relationship

________________________

________________________

Phone Number

___________________________

___________________________

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, _____________________________________________,

give my permission to Eureka College and/or its medical contractor to seek the necessary medical treatment

for ________________________________________________________________________________.

_________________________________________

Name of Parent/Guardian

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.)

I elect the College-sponsored Health and Sickness insurance (Premium to be added to student’s account).

I do not elect additional coverage under the College–sponsored Insurance plan.

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 SicknessInsurance outlined in Elections #1 and #2.

______ 1.

______ 2.

______ 3.

Signature _____________________________________________________________________________

Parent/Guardian if student is under 18 _______________________________________________________

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 stu-dent 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 INFORMATIONEureka 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 INSURANCEAll 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.

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In order to register for classes at Eureka College, the Student Health Questionnaire and Immunization Sheet must becompleted 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 condi-tions which the student has had or is currently experiencing.

Immunizations: To be completed by a physician (or health care professional licensed to provide immunizationverification). 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 firstbirthday 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 physician’s signed confirma-tion 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 student’s high school or PublicDepartment of Health is acceptable for review by Eureka College. It is not necessary for students born beforeJanuary 1, 1957 to demonstrate immunity.

Athletic Physical Forms are to be completed by a physician ONLY IF STUDENT IS PARTICIPATING IN ATHLETICS.

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

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

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college and state health personnel for health and educational purposes.

Name:________________________________________________ Birthdate:___/___/___ Sex: Male Female Last First Middle In case of emergency, contact:____________________________________ Relationship:_____________________

Address:_______________________________ City:___________________ State: ______ Zip Code:___________

Telephone: (H) _________________________________ (Cell) _________________________________

Yes No 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_________________________

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 physician’s care? Have you ever had any injury of:

Shoulder Wrist Hip Knee Ankle

Rhuematic Fever Renal Disease Low Blood Pressure Hernia

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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 ____ /____/____ Mumps ____ /____/____ Month Day Year 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.

To be completed by a physician or health care professional

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

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

Father’s Name:____________________________

Address:_________________________________

________________________________________

Employer________________________________

Address:_________________________________

_______________________________________

Telephone: ( ______ ) _______ - __________

Medical Insurance

Company or Plan:_________________________

Address:_________________________________

_______________________________________

Policy Number: ___________________________

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

Student Information(Required if student is covered under their own policy)

NAHGA - Policy #201ON1A14303 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? Yes No

City/State/Zip:_______________________________ Is a second opinion required before surgery? Yes NoPolicy Number: ______________________________ Is this plan an HMO or PPO? Yes No

Telephone: ( _____ ) ______ - ___________

MOTHER/GUARDIAN

Mother’s Name:___________________________

Address:_________________________________

________________________________________

Employer________________________________

Address:_________________________________

_______________________________________

Telephone: ( ______ ) _______ - __________

Medical Insurance

Company or Plan:_________________________

Address:_________________________________

_______________________________________

Policy Number: ___________________________

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

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(This side of the form is required to be completed by all athletes at Eureka College.)

AUTHORIZATION – To Permit Use and Disclosure of Health InformationThis Authorization was prepared by First Agency, Inc. and Eureka College for purposes of obtaining information neces-sary 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 inde-pendent 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 toEureka 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 disclo-sure of information is necessary to determine the level or validity of the claim payment. I also understand, once infor-mation 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 FirstAgency of Kalamazoo, MI. An extra premium is paid by the athlete, which varies by sport, before being eligible for par-ticipation. 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 ac-knowledge 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

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Dear Parents of Eureka College Intercollegiate Athletes,

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 rea-sons 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.

Injuries – Medical Bills – Insurance Coverage – 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.

1. Submit the bills incurred to your family insurance plan first.

They will take one of the following two actions:

A. Honor the claim and pay all or a portion of the bills incurred. B. 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.

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Sara Eggleston MS, ATC/LAsst. Athletic Trainer300 East College Avenue Eureka, IL 61530O: 309-467-6582F: 309-467-6402

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2. 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 1 Year Benefit Period

Guarantee Trust Life $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

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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 __________

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:

Name ___________________________________________________________________________________

Address __________________________________________________________________________________

City ___________________________________________ State __________________ ZIP _____________

Phone _______________________________________ Fax ________________________________________

FOR STUDENT-ATHLETES ONLY • ATHLETIC INFORMATION SHEET

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

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

Please list at least the Area Code of the newspaper.

22

ww2.eureka.edu or 192.168.10.15 (backup)

connectVisit 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.eduoff 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.

ath

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ATHLETIC PRE-PARTICIPATION PHYSICAL EVALUATION

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? 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 Elbow Knee Hip Wrist/Hand Ankle/Foot Back Forearm Shin Calf

Explain YES answers here: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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

Signature of Athlete _________________________________________ Date ______________________

Yes No

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.eduoff 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.

24

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PHYSICAL EXAM

Name __________________________________________________ Age____________ Date ________________

Height ___________ Weight ___________ Blood Pressure ______ / ______ Heart Rate ______________

Vision: Right 20/_____ Left 20/______ Corrected? Yes No Contacts Glasses

MEDICAL NORMAL ABNORMAL FINDINGS

Further Medical Evaluation Required:________________________________________________________________

Cleared to Participate Not cleared to participate Date __________ Phone _______________

Print Name ______________________________________ Signature ____________________________________

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)

1 2 3 4 5

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PERSONAL INFORMATION

Name: ________________________________________________________________

Student Commuter _____ Resident _____

Faculty Staff

VEHICLE INFORMATION License Plate #: ____________________

State: ______ Make: _______________

Model: ___________________________

Year: __________ Color: ____________

Signature: _____________________________________________________

Date: _________________________________________

SPS OFFICE USE ONLY

PERMIT INFORMATION

Parking Permit # : ____________________

Date Issued: _______ / _______ / _______

Date Expired: _______ / _______ / _______

REPLACEMENT INFORMATION

Parking Permit # : _____________________

Date Issued: _______ / _______ / _______

Date Expired: _______ / _______ / _______

VEHICLE REGISTERED TO: Name: ___________________________________

Address: __________________________________

City: _____________________________________

State: ______________ ZIP: _________________

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Parking and Permit Information 2012-2013Residential & 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 temporar-ily 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.

– 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

Bookstoreof Eureka College inside the Cerf Center

15%OFFALL EC APPAREL

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