steilacoom high school athletic registration form 8/05 ... · steilacoom high school athletic...

Steilacoom High School Athletic Registration Form 8/05

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Steilacoom High School Sentinels Football Registration Form

Student/Athlete Name ____________________________ Date _____/_____/_____ Grade Level _____ Year Entered 9th Grade ______________ Parent/Guardian Names _______________________ / ______________________ Student Address _____________________________________________________ City, State, Zip Code __________________________________________________ Home # _____-_______ Parents Work # _____-_______/_____-_______ Parents Cell # _____-_______ / _____-_______ The following forms need to be complete with parent/guardian signiture: ____ Risk Management Safety Guidelines ____ Athletic Eligibility Section ____ Insurance Section ____ Parent Consent and Assumption of Risk Section ____ Physicians Physical ____ Extra-Curricular Codes ____ Concussion Agreement ____ Physicians Physical Exam Attached Date of Exam _____/_____/_____ ____ Last Semesters Grades or Transcripts Athletic Director’s Signature (or AD staff) _____________________ Date _____/_____/_____


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FOOTBALL SAFETY GUIDELINES

This school strives to protect each student from possible injury while engaging in

school activities. The guidelines and information identified below have been established for this activity in order to protect the student and others from injury and/or illness. Participants and their parents should recognize that conditioning, nutrition, proper techniques, safety procedures, and well-fitting equipment are important aspects of this training program. Each participant is expected to follow the directions/standards of the coach and must understand that failure to follow such directions or adhere to standards may place the participant at risk

Travel to and from off-campus facilities shall be in accordance with the directions of

the activity coach. Guidelines are as follows: 1. Make certain that you wear all equipment that is issued by the coach. Advise the coach of any poorly-fitted or defective equipment. 2. Advise the coach if you are ill or have any prolonged symptoms of illness. 3. Advise the coach if you have been injured. 4. Engage in warm-up activities prior to strenuous participation. 5. Be alert for any physical hazards in the locker room or in or around the participation area. Advise coach of any hazard.

TACKLING, BLOCKING, AND RUNNING THE BALL Tackling and blocking techniques are basically the same. Contact is to be made

above the belt, but not initially with the helmet The player should always be in a position of balance, knees bent, back straight, body slightly bent forward, head up and the target area as near to the body as possible with the main contact being made with the shoulder. When properly blocking or tackling an opponent, contact with your helmet will naturally result. Therefore, technique is most important in order to prevent or reduce the likelihood of injury.

Blocking and tackling by not keeping the helmet as close to the body as possible

may result in a shoulder injury and a separation or a pinched nerve in the neck area. Injuries as a result of improper techniques can range from minor to disabling or even death. Improper body alignment can put the spinal column in a vulnerable position for injury. The development of strength in the neck muscles through isometric-type exercises will enable the participant to hold his/her head up even after getting tired during a workout or contest.

BASIC HITTING (CONTACT) POSITION AND FUNDAMENTAL TECHNIQUE

Strained muscle injuries can range from ankle injuries to serious knee injuries requiring surgery. The rules have made blocking below the waist (outside a two-yard by four-yard area next to the football) illegal.


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Cleats are restricted to no more than one-half inch to further help prevent knee injuries. A runner with the ball, however, may be tackled around the legs.

In tackling, the rules prohibit initial contact with the helmet or grabbing the face

mask on the edge of the helmet. Initial helmet contact may result in a bruise; dislocation; broken bone; head injury; or internal injury such as kidneys, spleen, bladder, etc. Grabbing the face mask or helmet edge may result in a neck injury which could result in injuries ranging from a muscle strain to a dislocation, nerve injury, or spinal column damage which could cause paralysis or death. EQUIPMENT

An athlete is required to wear all issued equipment. If equipment is damaged or does not fit correctly, the athlete must inform his coach immediately before use. Shoulder pads, helmets, hip pads, and pants (including thigh pads and knee pads) must have proper fitting and use.

A shoulder pad which is too small will leave the shoulder point vulnerable to bruises

or separations. A shoulder pad that is too tight in the neck area may result in a possible pinched nerve. A shoulder pad which is too large will leave the neck area poorly protected and will slide on the shoulders making them vulnerable to bruises or separations. Helmets must fit snugly at the contact points: front, back, and top of head. The helmet must be safety "NOCSAE" branded, the chin straps must be fastened, and the cheek pads must be of the proper thickness. A fit which is too loose could result in headaches, a concussion, a face injury such as a broken nose or cheekbone, or a neck injury that is possibly quite serious such as paralysis or even death.

The above information has been explained to me and l understand the list of rules

and procedures. I also understand the necessity of using the proper techniques while participating in the football program.

I am aware that tackle football is a high-risk sport and that practicing or competing

in tackle football will be a dangerous activity involving MANY RISKS OF INJURY. I understand that the dangers and risks of practicing and competing in tackle football include, but are not limited to, death, serious neck and spinal injuries which may result in complete or partial paralysis, brain damage, serious injury to virtually all internal organs, serious injury to virtually all bones, joints, ligaments, muscles, tendons and other aspects of my body, general health and well-being. I understand that the dangers and risks of practicing or competing in tackle football may result not only in serious injury, but in a serious impairment of my future abilities to earn a living, to engage in other business, social and recreational activities and generally to enjoy life.

Because of the dangers of tackle football, I recognize the importance of following

coaches' instructions regarding techniques, training and other team rules, etc., and to agree to obey such instructions.

I, _____________________________ am the parent/legal guardian of _____________________________ (student). I have read the above warning and release


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and understand its terms. I understand that tackle football is a HIGH-RISK SPORT involving many RISKS OF INJURY, including but not limited to those risks outlined above.

In consideration of the ______________________________ School District permitting my child/ward to try out for the ______________________________ School tackle football team and to engage in all activities related to the team, including, but not limited to, trying out, practicing or competing in, tackle football, I hereby assume all the risks normally associated with tackle football and agree to hold the School District, its employees, agents, representatives, coaches and volunteers harmless from any and all liability, actions, causes of action, debts, claims or demands of every kind and nature whatsoever which may arise from such risks. The terms hereof shall serve as a release for my heirs, estate, executor, administrator, assignees, and for all members of my family

We agree that neither the school district, nor the staff of the school district, nor the student

organization of the school district shall .in any way be held liable for any accident or injury in any way received on account of or while engaged in any athletic activity sponsored by the district. We further agree that neither the district nor any of their staff or student organizations shall be responsible for the payment of any bills rendered for medical services as a result of such accidents or injuries. We also acknowledge that it is our responsibility to provide for any medical, disability or other insurance to mitigate any costs that may be unfortunately incurred as a result of participation in this activity.

By signing below, I certify that I have read the above, understand its content, and

agree to its terms __________________________________ ____________________ Athlete's Signature Date __________________________________ ____________________ Parent's/Guardian's Signature Date


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Student Name _____________________________ Birth Date ____/____/____ Age _____ Athletic Eligibility To be filled out by the student/athlete: 1. I live in the Steilacoom School District True ____ False ____ 2. I have lived in the district continuously for more than one calendar year. True ____ False ____ 3. I have lived with the same parent(s)/guardian(s) continuously for more than one calendar year. True ____ False ____ 4. Steilacoom is the only school I have attended in the last calendar year True ____ False ____ 5. We do not own a home in another district. True ____ False ____ 6. I am under 20 years of age. True ____ False ____ 7. I attended school for the entire semester last semester. True ____ False ____ 8. I passed at least 7 classes (3. 5 credits) last semester. True ____ False ____ 9. I am presently enrolled in at least 7 classes (3. 5 credits) at Steilacoom. (this includes the “Running Start” program) True ____ False ____ 10. I have not been in high school (9-12) for more than four years. True ____ False ____ If any of your answers above were marked false, please explain why: ________________________________________________________________________________________________________________________________________________ 11. Are you currently enrolled in “Running Start”? Yes ____ No ____ 12. Are you a registered home school student? Yes ____ No ____ School attended last year ________________________________________ From ____/____/____ to ____/____/____ Student Signature _____________________Parent Signature ___________________ Date ____/____/____ Date ____/____/_____ Insurance I understand that it is strongly recommended that my son/daughter be covered by medical and dental insurance while participating in school sponsored athletics. I acknowledge, in case of injury to my son/daughter, the cost of treatment is my responsibility. (Initial one below)

_____ I have adequate insurance coverage with (medical) ___________________________ (Dental) ___________________________ ______ I do not have adequate insurance coverage and want to enroll my son/daughter in the School Athletic Insurance Program offered through the school district. I understand it is my responsibility to obtain the necessary forms from the school office. I accept full responsibility for the cost of treatment for any injury my son/daughter may suffer while participating in the school’s interscholastic athletic programs. Parent Signature ______________________ Date _____/_____/_____


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Parent Consent/Assumption of Risk Participation in athletics in the Steilacoom School District is a voluntary, extra-curricular activity. Participation in athletic activities can result in injury. The severity of such injury can range from minor cuts, scrapes and muscle strains or broken bones to catastrophic injury such as paralysis or death. No amount of reasonable supervision or training can completely eliminate the risk of possible injury. In consideration of the above warning and assumption of risk, I give permission for my daughter/son (name) _______________________ to participate in the athletic programs in the Steilacoom School District and engage in all activities related to their participation. Parent Signature _______________________ Date _____/_____/_____ Physical Exam I have read and accepted the recommendations by the examining physician and to the best of my knowledge, my daughter/son has had no serious injury/illness since their last physicians examination. Date of last physical exam _____/_____/_____ Athletic Code I have received and read a copy of the Steilacoom School District Athletic Code and agree to uphold the rules and regulations covered within. Parent Signature _______________________ Date _____/_____/_____ Student Signature _______________________ Date _____/_____/_____ Please circle the sport/activity your student intends to participate in this school year: Football Cheer Cross Country Soccer Tennis Volleyball Golf Step Team Swim/Dive Basketball Track and Field Baseball Fastpitch Wrestling


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Physical Examination Student Name:___________________________ Date ___/___/___ Age: ____ Pulse: ______ Urinalysis: ______ Body Fat %: ______ HCT: ______ Height: ______ Blood Pressure: ______ Weight: ______ Visual Acuity: Left 20/____ Right 20/____ Minimum weight for wrestling (required) Doctor: Circle and initial appropriate weight High School: 101 108 115 122 129 135 141 148 158 168 178 189 Unlimited Normal Abnormal Comments

1. Head _____- _____- ________________________________________ 2. Eyes _____- _____- ________________________________________ 3. Teeth _____- _____- ________________________________________ 4. Chest _____- _____- ________________________________________ 5. Lungs _____- _____- ________________________________________ 6. Heart _____- _____- ________________________________________ 7. Abdomen _____- _____- ________________________________________ 8. Genitalia _____- _____- ________________________________________ 9. Neurological _____- _____- ________________________________________ 10. Skin _____- _____- ________________________________________ 11. Physical Maturity _____- _____- ________________________________________ 12. Spine/Back _____-_____- ________________________________________ 13. Shoulders _____- _____- ________________________________________ 14. Upper Extremities _____- _____- ________________________________________ 15. Lower Extremities _____- _____- ________________________________________

Assessment: ____ Full Participation ____ Limited Participation (Describe limitations, restrictions) ________________________________________________________________________________________________________________________________________________________________ ____ Participation contraindicated (list reasons): ________________________________________________________________________________________________________________________________________________________________ Recommended equipment, taping rehabilitation, etc: ________________________________________________________________________________________________________________________________________________________________ Note: Physicals are good for 24 months unless otherwise indicated by the physician. Physicians Name (print) _______________________ Physicians Signature _______________________ Physicians # _____-_____-_______ Date _____/_____/_____


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Extra-Curricular Eligibility Code

The opportunity to participate in the interscholastic athletic programs or extra-curriculum club programs are a privilege granted to all students of the district. Participants in these voluntary programs are expected to conform to specific conduct standards established by the principals, coaches, advisors and athletic director. A student who is found by a certificated staff member of the student's school to be in violation of any rules is subject to removal from the team or club. Provision is made for a student who has allegedly violated one or more of the conduct rules to appeal a disciplinary action as specified in this code. All disciplinary actions shall be based on factual knowledge, as determined by the athletic director, club advisor and school administrators.

1. Attendance Student athletes and club members must be present a full school day on the day of practices, contests, or activity to be eligible to participate. Exceptions must be cleared through the athletic director or club advisor.

2. Grades a. Student athletes and club members must meet a minimum requirement of a 2.0 GPA

with no failing grades or have a 2.5 GPA or better with one F to be eligible to participate in contests. (See d and e for remedy options)

b. Student athletes and club members not meeting the minimum grade requirement may participate in team practice.

c. Student athlete and club members’ grades will be checked by the athletic director or club advisor following quarter, semester and progress grade reports.

d. Student athletes and club members not meeting minimum grade requirements for 14 calendar days from any classes will be banned from contest participation for a minimum of 7 calendar days, starting the Monday (or first school day if Monday is a non-school day) following a grade check.

e. Ineligible student athletes and club members are afforded the opportunity to complete a grade check on Thursday and Friday during the week of ineligibility to determine the next week’s eligibility standing.

f. A student athlete and club member may be required to complete a grade check for the purpose of eligibility at any time during the student’s athletic season.

g. All grade checks for ineligible athletes, club members, or athletes on probation will be conducted under the supervision of the athletic director and/or club advisor.

h. A student who does not meet the minimum academic grade requirements at the end of a semester will be ineligible to compete in athletic contests or club events through the 10th school day of the next semester. A valid grade check on that date is required to restore their eligibility for competition or participation (see section “2a” above).

i. A student participating in a fall sport or club activity which holds its district and/or state tournament in the spring will have his/her grades checked at the end of the 3rd quarter and be subject to the academic eligibility policy from that point until the conclusion of the spring sports season.


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3. Summer School, Correspondence and Online Courses In order to regain athletic or activity eligibility, students who would be considered ineligible may register for summer school, correspondence or online classes to correct deficiencies. The higher grade will be computed for eligibility purposes. Summer school, correspondence, and online courses must be pre-approved by the student’s counselor and must be completed, with grade recorded, prior to participation.

4. School Discipline All school discipline will supersede athletic events or club events. Exceptions must be approved by the athletic director, club advisor and building administrators.

5. In Season Sport or Club Change

Commitment is crucial to athletics or clubs and athletes and students are discouraged from switching sports or clubs in progress.

6. Doctor’s Physical and Release a. Student athletes must have a current physical exam on file in order to be cleared to

practice in a sport. The physical must be good for the entire season in order to be valid. b. Student athletes must obtain a doctor’s written release to resume participation in an

activity following an injury that requires medical attention. c. The written release must be kept on file in the athletic director’s office.

7. Cost to Participate

a. Student athletes as well as club members must purchase an ASB card. Athletes must also pay the sport user fee prior to the first athletic contest in a sport. Student athletes unable to pay for an ASB card and/or the sport user fee may request financial help through the counseling department.

b. Any athlete or club member on the fine list will not be allowed to participate in athletics or club events until the fine is paid in full or payment arrangements have been made with the school administration.

8. Team and Club Policies

All student athletes and club members will abide by the specific rules of the head coach, club advisor and the specific team.

9. Behavior During Transportation Participants are expected to behave in a safe and orderly manner while being transported to and from athletic and club events.

10. Conduct/Criminal Acts All student athletes and club members will refrain from disruption of school or school activities, poor citizenship, poor sportsmanship, use of alcohol or illegal drugs and all other illegal and criminal activities as defined by the Steilacoom School District, Town of Steilacoom, Pierce County and the State of Washington.


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11. Drugs, Drug Paraphernalia, and Alcohol: Possession, Use and/or Distribution Penalties for violation of RCW 69.41.020-69.41.050 Legend Drugs (WIAA Policy). Legend drugs including anabolic steroids possession, sale, and/or use or Violation of RCW 69.50 (Uniform Controlled Substances Act) – A violation of RCW 69.41.020-69.41.040 and alcohol shall be considered a violation of the eligibility code and standards, and shall subject the student to disciplinary actions. Legend drugs are defined as those drugs that are legal ONLY through prescription. Controlled substances and controlled substance analogs are defined in RCW 69.50.101. For the purposes of this rule, athletes or club members who attend an event where the possession, use or distribution of drugs, drug paraphernalia and/or alcohol is known by the athlete, that athlete has a duty to safely remove his or herself immediately from the event. Failure to do so is a violation of this rule and subject to these penalties. The following penalties will be administered: a. 1st Violation

A participant shall be immediately ineligible for interscholastic competition in the current interscholastic sports program for the remainder of that sport’s season (including post-season). Ineligibility shall continue until the next sports season in with the participant wishes to participate. In order to be eligible to participate in the next interscholastic sports season, the student athlete shall meet with the school eligibility board (see section 15 below).

b. 2nd Violation A student athlete or club member who again violates this rule shall be ineligible and prohibited from participating in any WIAA member school interscholastic sports program or club activity for a period of one calendar year from the date of the second violation.

c. 3rd Violation A student athlete or club member who violates this rule for a third time shall be permanently prohibited from participation in any WIAA member school athletic programs or club programs.

12. Tobacco a. 1st Violation

Student athletes or club members who have used tobacco during his/her sport season shall be suspended from participating in contests from the date that the administration learned of the offense and the following 21 calendar days. The 21 calendar day suspension period may be reduced to a 14 calendar day suspension if the student athlete completes an evaluation by a certified counselor and follows the recommendations of the program counselor who directs the student assessment. Practice privileges and club privileges will be determined by the student athlete’s head coach or club member’s advisor.

b. 2nd Violation Will result in suspension for the remainder of the current season.

c. 3rd or More Violations Will result in suspension from all interscholastic athletics and club activities for one calendar year from the date of the violation.


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13. WIAA and League Policies Participants shall comply with all WIAA and League policies, rules and regulations. (Refer to WIAA and League handbook)

14. Appeal Process All athletic and club membership appeals shall be initiated, in writing, through the athletic director. The athletic director will communicate a written decision on the appeal within 5 school days from receiving the grievance. The decision may then be appealed in writing to the eligibility board, through the principal or designee, within 5 school days of receiving the decision of the athletic director.

15. Eligibility Board

a. The athletic or membership eligibility board consists of one school administrator, the athletic director, three advisors, or three coaches (at least one coach must also be an in-building teacher).

b. The athletic or membership eligibility board will recommend in writing to the school administrator appropriate action to be taken in the student athlete or club member’s appeal.

c. The school principal or designee shall have the final authority as to the student athlete or club member’s participation in the interscholastic sports program or extra curriculum program.

Student Athlete:_______________________________Signature________________________ Date:____________________________ Parent: ______________________________________Signature________________________ Date:_____________________________

School Board Approved on Jan 27th, 2010


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Steilacoom High School

Concussion Information Sheet A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force transmitted to the head. They can range from mild to severe and can disrupt the way the brain normally works. Even though most concussions are mild, all concussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and managed properly. In other words, even a “ding” or a bump on the head can be serious. You can’t see a concussion and most sports concussions occur without loss of consciousness. Signs and symptoms of concussion may show up right after the injury or can take hours or days to fully appear. If your child reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself, seek medical attention right away. Symptoms may include one or more of the following:

• Headaches • “Pressure in head” • Nausea or vomiting • Neck pain • Balance problems or dizziness • Blurred, double, or fuzzy vision • Sensitivity to light or noise • Feeling sluggish or slowed down • Feeling foggy or groggy • Drowsiness • Change in sleep patterns

• Amnesia • “Don’t feel right” • Fatigue or low energy • Sadness • Nervousness or anxiety • Irritability • More emotional • Confusion • Concentration or memory

problems (forgetting game plays) • Repeating the same

question/comment

Signs observed by teammates, parents and coaches include:

• Appears dazed • Vacant facial expression • Confused about assignment • Forgets plays • Is unsure of game, score, or opponent • Moves clumsily or displays incoordination • Answers questions slowly


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• Slurred speech • Shows behavior or personality changes • Can’t recall events prior to hit • Can’t recall events after hit • Seizures or convulsions • Any change in typical behavior or personality • Loses consciousness

What can happen if my child keeps on playing with a concussion or returns to soon?

Athletes with the signs and symptoms of concussion should be removed from play immediately. Continuing to play with the signs and symptoms of a concussion leaves the young athlete especially vulnerable to greater injury. There is an increased risk of significant damage from a concussion for a period of time after that concussion occurs, particularly if the athlete suffers another concussion before completely recovering from the first one. This can lead to prolonged recovery, or even to severe brain swelling (second impact syndrome) with devastating and even fatal consequences. It is well known that adolescent or teenage athlete will often under report symptoms of injuries. And concussions are no different. As a result, education of administrators, coaches, parents and students is the key for student-athlete’s safety.


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If you think your child has suffered a concussion

Any athlete even suspected of suffering a concussion should be removed from the game or practice immediately. No athlete may return to activity after an apparent head injury or concussion, regardless of how mild it seems or how quickly symptoms clear, without medical clearance. Close observation of the athlete should continue for several hours. The new “Zackery Lystedt Law” in Washington now requires the consistent and uniform implementation of long and well-established return to play concussion guidelines that have been recommended for several years:

“a youth athlete who is suspected of sustaining a concussion or head injury in a practice or game shall be removed from competition at that time”

and

“…may not return to play until the athlete is evaluated by a licensed heath care provider trained in the evaluation and management of concussion and received written clearance to return to play from that health care provider”.

You should also inform your child’s coach if you think that your child may have a concussion Remember its better to miss one game than miss the whole season. And when in doubt, the athlete sits out.

For current and up-to-date information on concussions you can go to:

http://www.cdc.gov/ConcussionInYouthSports/ _____________________________ _____________________________ _____________ Student-athlete Name Printed Student-athlete Signature Date _____________________________ ______________________________ _____________ Parent or Legal Guardian Printed Parent or Legal Guardian Signature Date


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Dear Parent/Guardian, Steilacoom High School is currently implementing an innovative program for our student-athletes. This program will assist our athletic trainer in evaluating and treating head injuries (e.g., concussion). In order to better manage concussions sustained by our student-athletes, we have acquired a software tool called ImPACT (Immediate Post Concussion Assessment and Cognitive Testing). ImPACT is a computerized exam utilized in many professional, collegiate, and high school sports programs across the country to successfully evaluate and manage concussions. If an athlete is believed to have suffered a head injury during competition, ImPACT is used to help determine the severity of head injury and when the injury has fully healed. The computerized exam is given to athletes before beginning contact sport practice or competition. This non-invasive test is set up in “video-game” type format and takes about 15-20 minutes to complete. It is simple, and actually many athletes enjoy the challenge of taking the test. Essentially, the ImPACT test is a preseason physical of the brain. It tracks information such as memory, reaction time, speed, and concentration. It, however, is not an IQ test. If a concussion is suspected, the athlete will be required to re-take the test. Both the preseason and post-injury test data is given to the athletic trainer and a local doctor to help evaluate the injury. The information gathered can also be shared with your family doctor. The test data will enable these health professionals to determine when return-to-play is appropriate and safe for the injured athlete. The data will also help determine if academic accommodations are needed for the injured athlete so that they can be given time to recover quickly and safely. If an injury of this nature occurs to your child, you will be promptly contacted with all the details. I wish to stress that the ImPACT testing procedures are non-invasive, and they pose no risks to your student-athlete. We are excited to implement this program given that it provides us the best available information for managing concussions and preventing potential brain damage that can occur with multiple concussions. The Steilacoom High School administration, coaching, and athletic training staffs are striving to keep your child’s health and safety at the forefront of the student athletic experience. Please return the attached page with the appropriate signatures. If you have any further questions regarding this program please feel free to contact me at [email protected] or 253-983-2341. Sincerely, Joel McGuire, ATC/L CSCS Steilacoom High School Athletic Trainer


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CConsent Formonsent Form

For use of the Immediate Post-Concussion Assessment and Cognitive Testing

(ImPACT)

I have read the attached information. I understand its contents. I have been given an opportunity to ask questions and all questions have been answered to my satisfaction.

I agree to participate in the ImPACT Concussion Management Program.

Printed Name of AthletePrinted Name of Athlete ___________________________________

SpSportort ____________________________________

___________________________ _________________________

Signature of Athlete Date

___________________________ _________________________

Signature of Parent Date


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Steilacoom High School Student Emergency Information

Date _____/_____/_____

Student’s Name ____________________ Birth date ____/_____/_____ Age _____

Address _____________________________________________________________

Parents/Guardians Name _______________________ / ________________________

Home #_____-‐ _____-‐_______ Work # _____-‐_____-‐_______ / _____-‐_____-‐_______

Cell # _____-‐_____-‐_______ / _____-‐_____-‐_______

Emergency Contact (if parent/guardian is not available)

Name ________________________

Home # _____-‐_____-‐_______

Work # _____-‐_____-‐_______

Cell # _____-‐_____-‐_______

Doctor ________________________ Phone # _____-‐_____-‐_______

Preferred Hospital _______________________________________________________________

Allergies ________________________________________________________________________

Medical Concerns ________________________________________________________________________

I give permission for the team physician, Trainer or Coach to apply First Aid Treatment until a doctor can be contacted:

Yes ____ No ____.

Parent/Guardian Signature ________________________

We (parents/guardians) give consent for coaches, trainers and team physicians to use their own judgment in securing

medical and ambulance service in case the parent/guardian cannot be reached.


Your daughter/son is a member of a team, which plans to use school transportation. The school assumes no liability

beyond that of reasonable caution and care while conducting trips. I give my son/daughter permission to make these

trips during the current school year.


I give my permission for the Athletic Trainer to provide acute, modality, preventative, and rehabilitative treatment. I

also understand the Athletic Trainer will evaluate my athlete’s injury, make return to play decisions, and refer to a

physician when necessary.

Parent/Guardian Signature _____________________________

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