Rhinebeck Central School

Interscholastic Sports Participation Form

**This form MUST be returned 1 week prior to the beginning of the sport season to the Athletic Trainer 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

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:__________________