CMSD Emergency Medical Form
This form must be completed for students to participate in weightlifting at John Hay High School
EMERGENCY INFORMATION
Student - Last Name *
Your answer
Student - First Name *
Your answer
Student - Middle Name *
Your answer
Student - Birth Date *
MM
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DD
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YYYY
Sex *
Required
School *
Required
Graduation Year *
Street Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Parent / Guardian 1 - Name *
Your answer
Parent / Guardian 1 - Phone *
Your answer
Parent / Guardian 1 - Employer *
Your answer
Parent / Guardian 2 - Name
Your answer
Parent / Guardian 2 - Phone
Your answer
Parent / Guardian 2 - Employer
Your answer
Emergency Contact (if parent / guardian cannot be reached) - Name *
Your answer
Emergency Contact - Relationship *
Your answer
Emergency Contact - Address *
Your answer
Emergency Contact - Phone *
Your answer
Does your child have any medical condition or allergies which may require emergency treatment or to which a physician should be alerted? *
If you answered yes to the above question, please explain or answer "N/A" if you answered no. *
Your answer
PART I - TO GRANT CONSENT (If you choose to refuse consent, answer each item "N/A" and complete PART II.)
(This authorization does not cover major surgery unless the medical opinion of two other licensed physicians or dentists, concurring on the necessity for such surgery, are obtained prior to the performance of such surgery).

In the event that I cannot be contacted, I hereby give my consent for the administration of any treatment deemed necessary by:

Preferred Physician - Name *
Your answer
Preferred Physician - Phone *
Your answer
Preferred Dentist - Name *
Your answer
Preferred Dentist - Phone *
Your answer
Preferred Specialist - Name *
Your answer
Preferred Specialist - Phone *
Your answer
Preferred Hospital - Name *
Your answer
Preferred Hospital - Address *
Your answer
Preferred Hospital - Phone *
Your answer
PART II - REFUSAL TO CONSENT
I do not give my consent for emergency medical treatment of my child. I wish the school to take no action or to:
Please explain how you would like the school to proceed (or answer "N/A" if you completed PART I - TO GRANT CONSENT). *
Your answer
INTERSCHOLASTIC ATHLETICS INSURANCE COVERAGE
All students participating in the Interscholastic Athletics program are covered by a supplemental insurance policy through the Cleveland Metropolitan School District. This athletic coverage is provided by Arthur Gallagher Insurance Company and covers the following sports in out K-8 and Senior High Athletics Programs:

FOOTBALL, VOLLEYBALL, SOCCER, CROSS-COUNTRY, GOLF, BASKETBALL, SWIMMING, WRESTLING, BOWLING, SOFTBALL, BASEBALL, TRACK, TENNIS, WEIGHTLIFTING, CHEERLEADING, AND FENCING.

COVERAGE
Parents MUST submit their own family insurance claim first. The Board of Education Athletics’ coverage will then pay all other charges, which are in excess of the amount collectible from all other family insurance (maximum $2500). A student is covered while practicing for, competing in, or traveling to and from, athletic contest as a representative of a Cleveland Metropolitan K-8 and Senior High School. All events must be under the regulation and jurisdiction of the school and under the direct supervision of a full-time school employee. I release John Hay High School, and/or the State Board of Education, and the Interscholastic Athletic Office, of any and all medical, dental, and hospital expenses beyond the Interscholastic Athletic Insurance Coverage. Any and all expenses are the responsibility of the parent/guardian of the student athlete.

My child (choose one) *
Required
Medical Insurance Company - Name (answer "N/A" if the child does not have health insurance). *
Your answer
Medical Insurance Company - Policy Number *
Your answer
Dental Insurance Company - Name *
Your answer
Dental Insurance Company - Policy Number *
Your answer
ELECTRONIC SIGNATURE
By completing the questions below, you verify that all of the above information in this form is true and accurate.
Parent / Guardian - Name *
Your answer
Relationship to Student *
Your answer
Parent / Guardian - Street Address *
Your answer
Parent / Guardian - City *
Your answer
Parent / Guardian - Zip Code *
Your answer
Parent / Guardian - Phone *
Your answer
Today's Date *
MM
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