Interscholastic Sports Participation
Form
**This form MUST be returned
1 week prior to the beginning of the sport season and will be valid for one school
year.**
Student’s
Name:__________________________ Date of Birth:_________
Address:______________________________________________________
Grade:______ Home
Phone:_________ Cell Phone #’s:
______________
Mother
Business Phone:__________ Father Business Phone:____________
Sports Participating in:___________________________________________
Family
Physician:__________________________ Phone #:_____________
Family Dentist:____________________________ Phone #:_____________
Insurance
Company:________________________ Insurance
#:___________
Address:_________________________________ Phone #:_____________
Emergency
Contact Person:_______________________________________
Relationship/Home
& Cell Phone:___________________________________
Permission is granted for my child to actively participate on the above mentioned interscholastic athletic team(s).
In the event that I am unable to be
reached following an emergency or injury, I grant permission for the athletic
trainer, coach, or activity supervisor to seek and authorize any necessary
medical treatment, including medical transport.
I am aware that any such action will take place in the best interest of
my child.
SIGNATURE
OF PARENT: _____________________________________
PLEASE
HAVE NOTARIZED
Sworn to before me this _______ Day of _________,
20______
___________________________________________________
(Deputy) Clerk of the Court Notary Public
**PLEASE SEE OPPOSITE SIDE FOR FURTHER INFORMATION**
Interim Health
History/Screening Form
**Prior to the start of each sports season, a current health history review for each athlete MUST be conducted. This form must be completed, signed by the parent/guardian, and returned to the Athletic Trainer. .**
Athlete’s Name: ___________________________ Grade:_________
HEALTH HISTORY & STATUS SINCE
LAST MEDICAL EXAM*
1. Any injuries or serious illness since last medical exam? Yes______ No______
If yes, explain
2. Any illness requiring medication and/or under physician’s care at this time? Yes______ No______
If yes, explain
3. Any known allergies (i.e. medication, bee sting, etc.)? Yes______ No______
If yes, explain
4. Any chronic disease or condition (i.e. asthma/use of inhaler, diabetes, thyroid, etc.)? Yes______ No______
If yes, explain
5. Wears glasses/contact lenses or needs protective eyewear? Yes______ No______
If yes, explain
6. Need to use any protective device during sport activity (i.e. knee brace, mouth guard, etc.)? Yes______ No______
If yes, explain
7. Any feeling of faintness, dizziness, or fatigue after exercise? Yes____ No______
8. Any blood disorders (i.e. disease, frequent nose bleeds, etc)? Yes______ No______
If yes, explain
9. Any recent fracture or surgical operation? Yes______ No______
If yes, explain
10. Suffered a head injury or seizure? Yes______ No______
If yes, explain
11. Any impairment and/or loss of function such as eyes, kidneys, etc.? Yes______ No______
If yes, explain
12. Has there ever been a sudden death of a family member under 50 yrs. of age? Yes______ No______
If yes, explain
13. Any other pertinent condition which would either prohibit or cause him/her to be endangered by such participation? Yes______ No______
If yes, explain
14. List all current medications:
If yes, explain
*Answering “YES” to any of these questions does not mean
disqualification from sport.*
I, the undersigned, clearly understand that these questions are asked in order to decide if my child can safely participate on an athletic team. All answers are correct as of this date.
Parent/Guardian Signature:______________________________________ Date:__________________