Wisconsin Interscholastic Athletic Association Alternate Year Athletic Permit Card

WISCONSIN INTERSCHOLASTIC ATHLETIC ASSOCIATION ALTERNATE YEAR ATHLETIC PERMIT CARD

Physical Date _______________

SCHOOL YEAR 20__________ - 20__________

NAME _______________________________________________________________________ GRADE ________________ DATE OF BIRTH ______________________

Last

First

Middle Initial

Present Address __________________________________________________________________________________ Telephone ________________________________

Parents' Place of Employment _________________________________________________________________________________________________________________

Family Physician __________________________________________________________

Family Dentist ___________________________________________________

Name of Private Insurance Carrier ___________________________________________________________________ Telephone ________________________________

Subscriber Member Name (Primary Insured) _____________________________________________________________________________________________________

1. I hereby give my permission for the above named student to practice and compete and represent the school in WIAA approved sports.

2. I also attest to the fact that the above named student has had no injury or illness serious enough to warrant a medical evaluation prior to participating this school year.

3. Pursuant to the requirements of the Health Insurance Portability and Accountability Act of 1996 and the regulations promulgated thereunder (collectively known as “HIPAA”), I author-

ize health care providers of the student named above, including emergency medical personnel and other similarly trained professionals that may be attending an interscholastic event

or practice, to disclose/exchange essential medical information regarding the injury and treatment of this student to appropriate school district personnel such as but not limited to:

Principal, Athletic Director, Athletic Trainer, Team Physician, Team Coach, Administrative Assistant to the Athletic Director and/or other professional health care providers, for purposes

of treatment, emergency care and injury record-keeping.

4. It is recommended that information regarding your child’s allergies and prescribed medication be made available.

PARENT: If there is any question that this student may not be qualified for athletic competition without, at least, a partial re-evaluation, contact your medical advisor before signing card.

SIGNATURE OF PARENT __________________________________________________________________________

DATE ________________________________________

ALL STUDENTS PARTICIPATING IN INTERSCHOLASTIC ATHLETICS MUST HAVE THIS ALTERNATE YEAR CARD ON FILE AT THEIR SCHOOL PRIOR TO PRACTICE OR PARTICIPATION

WISCONSIN INTERSCHOLASTIC ATHLETIC ASSOCIATION ALTERNATE YEAR ATHLETIC PERMIT CARD

Physical Date _______________

SCHOOL YEAR 20__________ - 20__________

NAME _______________________________________________________________________ GRADE ________________ DATE OF BIRTH ______________________

Last

First

Middle Initial

Present Address __________________________________________________________________________________ Telephone ________________________________

Parents' Place of Employment _________________________________________________________________________________________________________________

Family Physician __________________________________________________________

Family Dentist ___________________________________________________

Name of Private Insurance Carrier ___________________________________________________________________ Telephone ________________________________

Subscriber Member Name (Primary Insured) _____________________________________________________________________________________________________

1. I hereby give my permission for the above named student to practice and compete and represent the school in WIAA approved sports.

2. I also attest to the fact that the above named student has had no injury or illness serious enough to warrant a medical evaluation prior to participating this school year.

3. Pursuant to the requirements of the Health Insurance Portability and Accountability Act of 1996 and the regulations promulgated thereunder (collectively known as “HIPAA”), I author-

ize health care providers of the student named above, including emergency medical personnel and other similarly trained professionals that may be attending an interscholastic event

or practice, to disclose/exchange essential medical information regarding the injury and treatment of this student to appropriate school district personnel such as but not limited to:

Principal, Athletic Director, Athletic Trainer, Team Physician, Team Coach, Administrative Assistant to the Athletic Director and/or other professional health care providers, for purposes

of treatment, emergency care and injury record-keeping.

4. It is recommended that information regarding your child’s allergies and prescribed medication be made available.

PARENT: If there is any question that this student may not be qualified for athletic competition without, at least, a partial re-evaluation, contact your medical advisor before signing card.

SIGNATURE OF PARENT __________________________________________________________________________

DATE ________________________________________

ALL STUDENTS PARTICIPATING IN INTERSCHOLASTIC ATHLETICS MUST HAVE THIS ALTERNATE YEAR CARD ON FILE AT THEIR SCHOOL PRIOR TO PRACTICE OR PARTICIPATION

WISCONSIN INTERSCHOLASTIC ATHLETIC ASSOCIATION ALTERNATE YEAR ATHLETIC PERMIT CARD

Physical Date _______________

SCHOOL YEAR 20__________ - 20__________

NAME _______________________________________________________________________ GRADE ________________ DATE OF BIRTH ______________________

Last

First

Middle Initial

Present Address __________________________________________________________________________________ Telephone ________________________________

Parents' Place of Employment _________________________________________________________________________________________________________________

Family Physician __________________________________________________________

Family Dentist ___________________________________________________

Name of Private Insurance Carrier ___________________________________________________________________ Telephone ________________________________

Subscriber Member Name (Primary Insured) _____________________________________________________________________________________________________

1. I hereby give my permission for the above named student to practice and compete and represent the school in WIAA approved sports.

2. I also attest to the fact that the above named student has had no injury or illness serious enough to warrant a medical evaluation prior to participating this school year.

3. Pursuant to the requirements of the Health Insurance Portability and Accountability Act of 1996 and the regulations promulgated thereunder (collectively known as “HIPAA”), I author-

ize health care providers of the student named above, including emergency medical personnel and other similarly trained professionals that may be attending an interscholastic event

or practice, to disclose/exchange essential medical information regarding the injury and treatment of this student to appropriate school district personnel such as but not limited to:

Principal, Athletic Director, Athletic Trainer, Team Physician, Team Coach, Administrative Assistant to the Athletic Director and/or other professional health care providers, for purposes

of treatment, emergency care and injury record-keeping.

4. It is recommended that information regarding your child’s allergies and prescribed medication be made available.

PARENT: If there is any question that this student may not be qualified for athletic competition without, at least, a partial re-evaluation, contact your medical advisor before signing card.

SIGNATURE OF PARENT __________________________________________________________________________

DATE ________________________________________

ALL STUDENTS PARTICIPATING IN INTERSCHOLASTIC ATHLETICS MUST HAVE THIS ALTERNATE YEAR CARD ON FILE AT THEIR SCHOOL PRIOR TO PRACTICE OR PARTICIPATION