Westlake Middle School Athletic Participation Form - WINTER
ALL FIELDS ARE REQUIRED
Permission to Participate
I give permission for my child to participate in the Mount Pleasant Central School District's Interscholastic Athletic Program. It is my understanding that my child will comply with the established policies and procedures of the Mount Pleasant Central School District and the Athletic Department. I will assume responsibility for paying fines incurred by my child for loss and/or damage to equipment, supplies and uniforms with the exception of normal wear. *
Required
Sports Warning *
We are aware that playing or practicing in any sport can be a dangerous activity involving MANY RISKS OF INJURY. We understand that the risks of engaging in sports, but are not limited to, death, serious neck and spinal injuries which may result in complete or partial paralysis, brain damage, serious injury to virtually all bones, joints, ligaments, muscles, tendons and other aspects of the muscular or skeletal system and serious injury or impairment to other aspects of the body, general health and well being. We also understand that the dangers and risks of engaging in the above sport may result not only in serious injury, but in a serious impairment of the future abilities of the athlete to earn a living, and engage in business, social and recreational activities and generally to enjoy life. Because of the risks described above, we recognize the importance of listening to and following all of the coach’s instructions and warnings regarding playing techniques, training methods, rules of the sport and other team rules in addition to the directions of the Athletic Trainer. We therefore expressly agree to obey all of the coach’s instructions and warnings in addition to the Athletic Trainer's. It is acknowledged that we have read and understand the implications of this sports warning.
Required
Student Information
Last Name *
Your answer
First Name *
Your answer
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Fall Sports *
Grade *
EMERGENCY MEDICAL TREATMENT INFORMATION
In the event that I cannot be reached and my child requires emergency medical attention, I hereby grant permission to a licensed physician designated by the Mount Pleasant CSD Coaching Staff to attend to my son/daughter in an appropriate medical setting. *
Required
Parent 1 Name *
Your answer
Parent 1 Home Phone *
Your answer
Parent 1 Cell Phone *
Your answer
Parent 2 Name *
Your answer
Parent 2 Home Phone *
Your answer
Parent 2 Cell Phone *
Your answer
Family Physician *
Your answer
Family Physician Phone *
Your answer
Family Dentist *
Your answer
Family Dentist Phone *
Your answer
Emergency Contact Person Other than Parent/Guardian *
Your answer
Emergency Contact Phone Number Other than Parent/Guardian *
Your answer
Medical History and Update
The athlete is not cleared to participate until the school physician/school nurse have reviewed and verified the current physical exam and medical records, and have cleared the student for interscholastic athletic participation.
Date of Physical Exam - Please enter the date below. *
Nurse will verify information. A student who engages in interscholastic competition MUST have completed the required physical examination. The student may not begin practice without the required medical documentation and approval by the School District Medical Personnel. A PHYSICAL EXAM MUST BE DATED ON OR AFTER November 1, 2016. TO BE CLEARED TO PARTICIPATE, A COPY OF THE CURRENT PHYSICAL MUST BE ON FILE IN THE NURSES OFFICE.
MM
/
DD
/
YYYY
List any allergies *
if none, please state 'none'
Your answer
Epi-Pen *
Asthma (including exercise induced) *
Inhaler *
Diabetes *
Insulin Pump *
Glucose Sensor *
Seizures *
Is your child taking any medicine, OR taking any performance enhancing substances and/OR under a physician's care at this time? *
If yes, please explain and list any current medications. A doctor's note must be submitted to the nurse for use of medication during Athletics and the note should include if the child is self directed. If no, state 'none'. *
Your answer
Has your child ever had a head injury/concussion, requiring medical attention? *
Has any relative been diagnosed with a heart condition or developed hypertrophic cardiomyopathy, Marfan Syndrome, right ventricular cardiomyopathy, long QT or short QT syndrome? *
Has any relative died suddenly before the age of 50 from unknown or heart related causes? *
Does your child have any heart/circulatory conditions, or has he/she had any feelings of faintness, dizziness, fatigue or short of breath after exercise or exertion? *
Has your child ever complained of fluttering in their chest, skipped beats, heart racing or does he/she have a pacemaker? *
Has your child ever become ill while exercising in hot weather? *
Has your child ever wheezed or coughed frequently during or after exercise? *
Does your child have high or low blood pressure? *
Has your child had any communicable diseases in the past year? *
Has your child had any treatment in a hospital or emergency room this past year? *
Has your child had any illness/injury lasting more than five (5) days this past year? *
Does your child wear glasses or contacts, please indicate which below? *
Has your child had any surgical operations, organ removal or fractures in the past year? *
Does your child have a chronic disease? *
EXPLAIN ANY 'YES' ANSWERS TO THE ABOVE QUESTIONS AND INCLUDE DATES: If 'none', please state none. *
Your answer
I acknowledge that the above information is correct and my son/daughter still remains in good health. *
Required
Consent for Use of Photographs/Digital Images and Release of Information for Student-Athletes
I, the parent of the above named student, a student in the Mount Pleasant Central School District, do hereby consent to the release of certain personally-identifiable information pertaining to my son/daughter related to participation in the Mount Pleasant CSD Athletic Program during the 2017-2018 school year. The information may include the student's name, grade, sport(s) of participation, gender, jersey number, height, weight, game, seasonal or team participation statistics, awards received, previous and future institutions of attendance, photographs/digital images or videotapes of students in media print, school newspapers, the District's website or other electronic and broadcast outlets.

I am over the age of 18, have read the above information, I understand the information and will be bound by its terms on my own behalf and on behalf of my child. This information will not be released if the School District determines that the information will be used for commercial, solicitation or fundraising purposes.

Release for Photographs/Digital Information *
Please choose one of the two options below
Concussion Management Information
Concussion Management Information *
Please review the following links to required NYS Concussion Management Education Information: NYS Department of Health: http://www.health.ny.gov/prevention/injury_prevention/concussion.htm NYS Department of Education: http://www.p12.nysed.gov/sss/schoolhealth/schoolhealthservices/ConcussionManageGuidelines.pdf
Required
ImPACT Testing
ImPACT Testing *
Permission for use of the Immediate Post-Concussion Assessment and Cognitive Testing (ImPact) test. Kindly complete even if you believe your student has been tested. Re-testing of baseline is performed every 2 years. Information of the ImPACT Management Program: http://impacttest.com/about/background
Transportation Information
Please indicate below if you agree to accept full responsibility for your child's well being while providing transportation from away competitions. I the Parent/Guardian, will be the responsible party for the return trip to the school from an athletic event, when I am available to provide transportation. This will be in effect for the entire current sports season. I fully realize that in authorizing this procedure, I hereby remove the school from any liability and/or responsibility regarding return travel from away athletic events while providing such transportation. *
By printing your name here you agree that you have filled out this form and all of the information above is accurate to the best of your knowledge. By completing this form you hereby certify that you are the parent/legal guardian of the child listed above. By entering your name and selecting “SUBMIT” you acknowledge that among the information provided about yourself or your child may require the submission of what may be considered personal or confidential information, such as your name, your child’s name, medical information, contact information, and other private information. When you submit information to the Mount Pleasant Central School District “MPCSD”, you understand and agree that MPCSD may store your information in a secure manner on its servers. MPCSD will utilize due diligence and prudent efforts to protect such information as would be considered good practice with regard to electronically stored data. MPCSD appreciates the importance of responsible use of this information and will not share it with any third party without express consent by you. If you choose to provide us with information via this form we will use that information only to complete the request specified by that form and to make contact with you with regard to the services on our site for which you have expressed interest.
Parent/Guardian Type Your Full Name *
Your answer
Parent/Guardian Home Address
Your answer
Parent/Guardian Email Address *
Please put an email address so if there are any questions, we can contact you.
Your answer
Please hit the submit button ONLY ONCE, then wait for a message confirming your submission before exiting.
Submit
Never submit passwords through Google Forms.
This form was created inside of Mount Pleasant Central School District. Report Abuse - Terms of Service - Additional Terms