Byram Hills HS Winter 2016-17 Athletic Participation Form

ALL FIELDS ARE REQUIRED

    Permission to Participate

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    Student Information

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    EMERGENCY MEDICAL TREATMENT INFORMATION

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    Medical History and Update

    The athlete is not cleared to participate until the physical exam date has been verified.

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    Consent for Use of Photographs/Digital Images and Release of Information for Student-Athletes

    I, the parent of the above named student, do hereby consent to the release of certain personally-identifiable information pertaining to my son/daughter related to participation in the Byram Hills Athletic Program during the 2016-17 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, on BobcatTV the District's website or other electronic and broadcast outlets.

    I am the parent/legal guardian of the child listed above. I have read the above information and 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.
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    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
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    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
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    Transportation Information

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    By printing your name below 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 Byram Hills Central School District “BHCSD”, you understand and agree that BHCSD may store your information in a secure manner on its servers. BHCSD will utilize due diligence and prudent efforts to protect such information as would be considered good practice with regard to electronically stored data. BHCSD 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.

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    Please email or fax a copy of your child's current physical to: Julie Gallagher (jgallagher@byramhills.org) or fax # (914) 273 - 1256

    Please hit the submit button ONLY ONCE, then wait for a message confirming your submission before exiting.