Athletics Physical Form - Aylett Country Day School printable pdf download

AYLETT COUNTRY DAY SCHOOL

P.O. BOX 70, MILLERS TAVERN, VIRGINIA 23115

Athletic Participation/Parental Consent/Physical Examination Form

PLEASE PRINT CLEARLY

Separate signed form is required for each school year.

Grade and School Year

Male ___

Female ____

Date of Birth

Name

(Last)

(First)

(Middle Initial)

Home Address

Home Address of Parents

ACKNOWLEDGEMENT OF RISK AND INSURANCE STATEMENT

(To be completed and signed by parent/guardian)

I give permission for ____________________________ (name of child) to participate in athletic events, physical education and the physical

evaluation for the participation. I am aware that with the participation in sports comes the risk of injury to my child. I understand that the

degree of danger and the seriousness of the risk varies significantly from one sport to another with contact sports

carrying the higher risk. I have had an opportunity to understand the risk inherent in sports through meetings, written handouts, or

some other means. He/she is insured by our family policy with:

Name of Medical Insurance Company:

Policy Number:

Name of Policy Holder:

I am aware that participating in sports will involve travel with the team. I acknowledge and accept the risks inherent in the sport and

with the travel involved and with this knowledge in mind, grant permission for my child to participate in the sport and travel with the team.

By this signature, I hereby consent to allow the physician(s) and other health care provider(s) selected by myself or the school to

perform a pre-participation examination on my child and to provide treatment for any injury or condition resulting from participating

in athletics/activities for his/her school during the school year covered by this form. I further consent to allow said physician(s) or

heath care provider(s) to share appropriate information concerning my child that is relevant to participation in athletics and activities with

coaches and other school personnel as deemed necessary.

EMERGENCY PERMISSION FORM

(To be completed and signed by parent/guardian)

Please list any significant health problems that might be significant to a physician evaluating your child in case of an emergency.

Please list any allergies to medications, etc. __

Is the student currently prescribed an inhaler or Epi-Pen? ______ List the emergency medication:

Is student presently taking any other medication? _________ If so, what type?

Does student wear contact lenses? ____________________ Date of last tetanus shot

EMERGENCY AUTHORIZATION: In the event I cannot be reached in an emergency, I hereby give permission to physicians

selected by the coaches and staff of Aylett Country Day School to hospitalize, secure proper treatment for and to order injection and/or

anesthesia and/or surgery for the person named above.

Emergency Contact Numbers: Daytime: _______

Evening:

Cell phone

►►Signature of parent or guardian

Date

Relationship to student

*Emergency Permission Form may be reproduced to travel with respective teams and is acceptable for emergency treatment if needed.

Athletics Physical Form - Aylett Country Day School

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