University of Arkansas – Fort Smith SICKLE CELL TRAIT

University of Arkansas – Fort Smith

SICKLE CELL TRAIT INFORMATION SHEET

The NCAA has established a new protocol for testing student athletes for sickle cell

trait. Student athletes must either be tested for sickle cell trait, provide documented

results of a prior sickle cell trait test, or sign a waiver if they decline to be tested. The

NCAA and the University of Arkansas - Fort Smith recommend student athletes undergo

testing for sickle cell trait.

Information about Sickle Cell Trait:

Sickle cell trait is the inheritance of one gene for sickle hemoglobin and one for normal

hemoglobin. Sickle cell trait is a life-long condition that will not change over time. People

at high risk for having sickle cell trait are those whose ancestors come from Africa,

South or Central America, India, Saudi Arabia and Caribbean and Mediterranean

countries. Although universal screening is required at birth, many student-athletes do

not know their status.

Usually, people with sickle cell trait do not have any medical problems and they can

lead normal lives. However, sickle cell trait can change the shape of red blood cells

during intense or extensive exertion, causing a blockage in blood vessels and rapid

breakdown of muscles, including the heart, which may lead to a collapse or even death.

More information regarding sickle cell trait and the NCAA’s recommendation for sickle

cell trait testing can be found at the official website for the NCAA (www.ncaa.org).

Please indicate which of the following you plan to provide to the UAFS Sports

Medicine Department. You will NOT be able to participate in any activity related to

your sport this year until documentation is provided:

□ A copy of “Certification of Sickle Cell Trait” signed by your physician. These

records will likely be available at either the birth hospital or at the office of a long

time family physician.

□ A signed copy of the “Sickle Cell Waiver Form” available on the UAFS athletics

website or,

□ There will be sickle cell testing on site during physicals on August 21, 2012. The

cost of the test is $10 and will be the responsibility of the student-athlete.

Please sign and return this form by 08/01/2012 in order for the student-athlete to

participate in team activities.

Student-athlete Name:________________________ Signature:_______________________

University of Arkansas – Fort Smith

SICKLE CELL TRAIT TESTING WAIVER FORM

1. By signing this waiver, I am certifying that I understand that the NCAA and the

University of Arkansas – Fort Smith recommend that all student athletes undergo

testing for sickle cell trait. Furthermore, I have read and fully comprehend the

aforementioned facts regarding sickle cell trait.

2. By providing my signature below, I confirm that I do not wish to undergo testing

for sickle cell trait. In consideration of this waiver, I hereby RELEASE, WAIVE,

HOLD HARMLESS, INDEMNIFY, DISCHARGE, AND CONVENANT NOT TO

SUE the University, its Trustees, officers, agents, or employees from any and all

liability, claims, actions, demands, expenses, attorney fees, breach of contract

actions, breach of statutory duty or other duty of care, warranty, strict liability

actions, and causes of action whatsoever, that may arise from my (or my minor

child’s) decision to forego sickle cell trait testing.

3. In signing this Sickle Cell Trait Testing Waiver Form, I acknowledge and

represent that I have read the entirety of the Sickle Cell Trait Information Sheet

and Waiver Form, that I understand it and sign it voluntarily, and that no oral

representations, statements, or inducements, apart from the foregoing written

document have been made to me on the subject matter of this document which

have otherwise caused me to sign this waiver form, that I am fully competent,

and that I execute this Waiver for full, adequate, and complete consideration fully

intending for me (and my minor child) to be bound by the same.

I further certify that:

□ I am at least eighteen (18) years of age and fully competent; or that I am

□ Under eighteen (18) years of age, and my parent or guardian is also signing

individually and on my behalf and we both agree to be bound by the terms of this Sickle

Cell Trait Testing Waiver Form.

Name:_____________________________________ Date: __________________

Signature: _________________________________

Parent/Guardian Signature (if participant is under 18): ________________________

*** If you have any questions about this waiver form, you should contact:

Angela Mierzwiak

UAFS Sports Medicine

479-788-7686