Form Mu-Ssm-12 - Youth & Young Adult Ministry And Cyo Office - Cyo Athletic Preparticipation - 2015

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YOUTH & YOUNG ADULT MINISTRY AND CYO OFFICE – CYO ATHLETIC PREPARTICIPATION FORM

(PLEASE TYPE OR PRINT)

STUDENT'S NAME _____________________

_____________ __

BIRTH DATE____________ SEX ____ GRADE _______

LAST

FIRST

ADDRESS_____________________

___________

__________

SCHOOL

STREET

ITY

ZIP

PARISH

PARISH CITY

PARENT/GUARDIAN(S) NAME

MOBILE/WORK TELEPHONE NO.

HOME TELEPHONE NO.

Carefully complete the following questions before your physical exam. Explain “YES” answers below.

YES

1. Has this athlete ever had hospitalization, surgery, injury, serious medical or psychological illness?.................................... ___

___

2. Is this athlete now under the care of a physician or taking any medication?............................................................................. ___

___

3. Has any physician ever recommended or do you feel that there should be limits placed on

participation in competitive sports by this student?..................................................................................................................... ___

___

4. Does this athlete have any known allergies? (medication, pollen, food, stinging insects).........................................................

___

5. Does this athlete wear glasses or contact lenses? Give date of last eye exam if "YES".......................................................... ___

___

6. Has this athlete ever blacked out, been knocked out, lost consciousness or been dizzy during or after physical activity? ___ ___

7. Has this athlete ever had racing of the heart, skipped heart beat or heart murmur? ……………………………………………. ___

___

8. Has this athlete ever had a head injury or concussion?………………………………………………………………………………. ___

___

9. Has this athlete ever had a seizure?……………………………………………………………………………………………………… ___

___

10. Does this athlete use special protective/corrective equipment that isn’t usually used?

(For example knee brace, ankle brace, foot orthotics, hearing aid, etc.) ……………………………………………………………….. ___

___

11. Does this athlete lose weight regularly to meet weight requirements for the sport?……………………………………………. ___

___

Explain any YES answers:

I/we, the undersigned consent to the participation of the above-named child in CY O athletics including practice sessions, scrimmages and athletic

contests. In consideration of participation in these programs, and wishing to promote and benefit this non-profit cause, I/we, the undersigned

participant/parent, on behalf of myself, my heirs, legatees, and assigns, hereby agree to indemnify, save, and hold harmless the Catholic Charities Corporation

dba Catholic Charities, Diocese of Cleveland (CCDC), the Bishop of the Catholic Diocese of Cleveland , the Catholic Diocese of Cleveland, sponsoring

Parishes/Schools and any of their agents, representatives, employees, volunteers, successors or assigns for my health, safety or any injury and/or disability

arising out of or resulting from: (CHECK all programs that apply)

CROSS COUNTRY

FOOTBALL

VOLLEYBALL

SOCCER

CHEERLEADING

BASKETBALL

WRESTLING

BASEBALL

SOFTBALL

TRACK & FIELD

As a participant/parent in the program, I/we recognize and acknow ledge that there are certain risks of physical injury and I/we agree to assume the

full risk of any injuries, including loss of life, damages or loss which I/we may sustain as a result of participating in any and all activities connected with or

associated with such program. The undersigned acknowledge that the participant has prepared for the sport in which participating by adequately conditioning

and practicing. I/we hereby represent that I have no physical restrictions that would prohibit my participation in the sport that I have selected. The Youth &

Young Adult Ministry and CYO Office has my permission to have a physician attend me if deemed necessary during my participation in this CYO program.

I/We also give permission and authorize CCDC, it agents, employees, successors and assigns to photograph or otherwise electronically or digitally

record my image, or that of my child for w hich I am guardian participating in these athletic programs for the publication in printed or electronic form to be seen

and disseminated to the general public in any media including CCDC newsletter, poster, display, film, video or website.

I/we further agree to waive and relinquish all claims, fully release and discharge and agree to indemnify and hold harmless and defend the CCDC,

Youth & Young Adult Ministry and CYO Office and its officers, agents, servants, volunteers and employees from any and all claims resulting from injuries, including

loss of life, damages and losses sustained by me and arising out of, connected with, or in any way associated with activities of the program.

Participants Signature __________________________________________________________________

Date _____________________

Parent or Guardian Signature ___________________________________________________________

Date _____________________

Parent or Guardian Signature __________________________________________________________

Date _____________________

This athlete has family medical insurance:

YES

NO If yes, the Child is covered by:

INSURANCE COMPANY: _____________________________________ POLICY NO. __________________________ EFFECTIVE DATE: ___________

HISTORY AND CONSENT MUST BE COMPLETED PRIOR TO PHYSICAL EXAM