WCSD - Health History Form
WINDSOR CENTRAL SCHOOL DISTRICT STUDENT-ATHLETE HEALTH HISTORY UPDATE
NO STUDENT ATHLETE WILL BE ALLOWED TO PARTICIPATE UNTIL A HEALTH HISTORY FORM IS SUBMITTED
Email address *
Cannot pre-fill email address.
Athlete Name (First name) *
Your answer
Athlete Name (Last name) *
Your answer
Grade *
Required
Sport Level *
Required
Sport *
Required
Parent / Guardian #1 (First Name Last Name) *
Your answer
Parent / Guardian Email address
Your answer
Parent / Guardian #1 Relationship *
Required
Parent / Guardian #1 Phone Number(Home) *
Your answer
Parent / Guardian #1 Phone Number(Cell) *
Your answer
Parent / Guardian #1 Phone Number(Work)
Your answer
Parent / Guardian #2 (First Name Last Name) *
Your answer
Parent / Guardian #2 Relationship *
Required
Parent / Guardian #2 Phone Number(Home) *
Your answer
Parent / Guardian #2 Phone Number(Cell) *
Your answer
Parent / Guardian #2 Phone Number(Work)
Your answer
Emergency Contact Name (First Name Last Name) *
Your answer
Emergency Contact Relationship *
Your answer
Emergency Contact Phone Number(Home) *
Your answer
Emergency Contact Phone Number(Cell) *
Your answer
Emergency Contact Phone Number(Work)
Your answer
Athletic Code of Conduct will be followed as stated in the Windsor Student Handbook *
Required
RISK OF INJURY NOTICE I am aware that competing and practicing in any extracurricular athletic activity can be a dangerous. I understand that the inherent dangers and risks of competing and practicing include, but are not limited to, death, neck and spinal injury which may result in complete or partial paralysis, brain damage, injury to virtually all bones, joints, ligaments, muscles, tendons and other aspects of a muscular-skeletal system and injury or impairment of future abilities to earn a living, to engage in business, social and recreational activities and generally to enjoy life. Although I am aware that certain activities, for example, cheerleading, baseball, field hockey, softball, football, soccer, basketball or wrestling, may involve greater inherent risks of injury, I acknowledge that other activities can also result in serious injury or death. Because of the possible inherent dangers of participating in extracurricular activities, I recognize the importance of following the coaches' instructions regarding playing techniques, training and other team rules and agree to obey such instructions. In consideration of the school district's permitting me to try out for and to engage in all activities related to the team including, but not limited to, trying out, practicing or participating in that activity, I hereby assume all inherent risks associated with participation. Please refer to the links below to learn more about concussion management…http://nysphsaa.org/portals/0/pdf/safety/StudentParentConcussionInformation.pdfhttp://www.p12.nysed.gov/sss/documents/ConcussionManageGuidelines.pdf The undersigned, person in parental relationship of the individual who has signed the Risk of Injury Statement, hereby acknowledges receipt of the Risk of Injury Statement and acknowledges awareness of the various inherent risks set forth in the statement and, considering such risks, gives permission for the student to participate in an extracurricular athletic activity. If I withdraw my permission, I understand that the withdrawal must be in writing and given to the athletic director as well as to the coach of the particular athletic activity.
Has anything changed in your child's health since his/her last physical examination? Please explain.
Your answer
Please list any important medical information/allergies the coach should be aware of.
Your answer
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