High School Athletic Pre Participation Exam Form Page 2
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1
2HIGH SCHOOL ATHLETIC CONSENT FORM
Name: _________________________
_____________________ I.D.# ________________
___/___/___
GR._____
M/F
Last
First
Birth Date
(In Fall)
Circle
Parent /Guardian Name: ___________________________
__________________________
Hm. Phone: (
) _____________
Wk. Phone: (
) _____________
Last
First
Cell Phone: (
) _____________
Address: _______________________________________________________________________
EMERGENCY CONTACT IN THE EVENT PARENT/GUARDIAN CANNOT BE REACHED:
Name: ___________________________________
________________________________
Hm. Phone: (
) ______________
Wk. Phone: (
) ______________
Last
First
Cell Phone: (
) ______________
Relationship:
Parent
Guardian
Step Parent
Relative
Friend
Name: ___________________________________
________________________________
Hm. Phone: (
) ______________
Wk. Phone: (
) ______________
Last
First
Cell Phone: (
) ______________
Relationship:
Parent
Guardian
Step Parent
Relative
Friend
PLEASE READ EACH STATEMENT AND SIGN AT THE BOTTOM
I.
CONSENT FOR EMERGENCY TREATMENT
Treatment Consent: In the event of an accident or emergency, I (we) give permission for the school authorities to take my (our) child
to any doctor or hospital, or request their services. If not, please advise the school as to what action you would like to be taken:
_________________________________________________________________________________________________________________
Athletic Trainer Consent: I give my permission to the Athletic Trainer to administer first aid, follow-up treatment and rehabilitation
when appropriate in his/her professional judgment, as approved by the consulting physician.
YES OR NO
II.
MEDICATION DURING ATHLETICS
My child may need medication during school hours, athletic practices, field trips, or competitions. This may include prescription
medication, such as inhalers or EpiPen OR over-the-counter medication such as Advil or Tylenol. I understand that my child’s
physician and I, as the parent/guardian, need to complete an IUSD Parent/Guardian and Physician Request for Medication form
which can be obtained from the school Health Office or
YES OR NO
III.
MUSCULOSKELETAL SCREENING CONSENT
I authorize permission for my child to receive an Athletic Pre-Participation Musculoskeletal Screening at my child’s school.
I
understand that this does not replace the athletic pre-participation physical exam by my child’s Healthcare Provider.
YES OR NO
IV.
INSURANCE CERTIFICATION
I hereby certify that my child is insured for accidental death insurance in the amount of $1,500 and for at least $1,500 insurance
protection for medical and hospital expenses resulting from accidental bodily injury while participating in inter-school athletic
events or while being transported to and from such athletic events.
YES OR NO
Please check one of the following:
____ My child is insured for the above activity under our family Health/Medical Plan.
PPO – HMO – KAISER – OTHER (circle one)
Name of Company
____ I have purchased the school insurance plan.
V.
TRANSFER ELIGIBILITY
Has student attended ANY other High School?
If yes, name of school ___________________________________
YES
OR
NO
VI.
COMMUNICATION PROCEDURES
I understand that the orderly use of the following procedures is suggested when offering input to the Athletic Department, and that
written documentation is recommended.
1. Discuss needs, complaints or concerns with the Coach.
2. If not satisfied, request a conference with the Athletic Director.
3. If individual conferences with Coach and Athletic Director are not satisfying, then a conference with all parties
will be held with the Assistant Principal of Athletics.
4. If the athlete and/or parent(s) are still not satisfied, then an appeal may be made to the Principal.
5. I have read and understand the Athletic Code.
VII.
PARENT OR GUARDIAN CONSENT
I hereby give my consent for the above named student to compete in IUSD approved activity programs such as: Sports, Marching
Band, Cheerleading Squad, etc. and travel with the school representative on necessary school trips. I realize that there is a risk of
serious injury or death from participating in school sports and related activities. It is understood that the school district, the
student body, and/or any of the employees are not financially responsible in case of accident or injury.
Date:
Signature of Parent/Guardian:
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