2018-2019 Parent & Student Yearly Athletic Waiver and Agreement Forms
ASHS Athletic Participation Requirement
Email address *
Student-athlete LAST name *
Your answer
Student-athlete FIRST name *
Your answer
Student-athlete GRADE in Fall 2018/Spring 2019 *
Student-athlete :: Indicate which FALL 2018 sport you would like to tryout for *
Your answer
Student-athlete :: Indicate which WINTER 2018/2019 sport you would like to tryout for *
Your answer
Student-athlete :: Indicate which SPRING 2019 sport you like to tryout for *
Your answer
CONSENT to MEDICAL TREATMENT AGREEMENT - Student-athlete *
I acknowledge and agree that all future injuries and/or illnesses, such as those related to medical, dental, mental health, any type of surgical procedure, ailments, complaints, re-injuries or aggravations of old injuries and/or illnesses must be immediately reported to my parent/guardian and my ASHS Certified Athletic Trainer(s), and ASHS Coach(es) no matter how minor or insignificant I may deem them to be.
Required
CONSENT to MEDICAL TREATMENT AGREEMENT - Parent/Guardian *
I hereby consent to allow the ASHS Team Physician(s), ASHS Certified Athletic Trainer(s) and other health care provider(s) selected by myself or ASHS to perform a pre-participation examination on my student-athlete and to provide treatment for any injury and/or illness received while participating in or training for athletics at ASHS. Permission is also granted for the ASHS Certified Athletic Trainer(s), under the direct supervision of the ASHS Team Physician to proceed with any use of modalities for the care, treatment and rehabilitation of my student-athlete for injuries and/or illnesses sustained during ASHS athletic related events or training. Treatment such as first aid, diagnostic procedures, rehabilitation exercises and therapeutic modalities that may be provided by the treating Physician(s), Physician’s Assistant, Nurse Practitioner, Certified Athletic Trainer(s) or other healthcare providers employed directly or through a contract with ASHS or the opposing team’s medical staff. Modalities will only be utilized under the standing orders of the Team Physician(s) and/or orthopaedic surgeon or treating medical provider and will only be administered by the Certified Athletic Trainer(s). Additionally, I authorize the use of Neurocognitive Testing Programs for the management of concussions. I further consent to allow said Team Physician(s), Certified Athletic Trainer(s), or healthcare provider(s) to share appropriate information concerning my student-athlete that is relevant to participation, with coaches, medical staff, and other school personnel as deemed necessary. Such information may be used for injury surveillance purposes. I acknowledge that ASHS Certified Athletic Trainer(s) follow well-established concussion management protocols to keep my student-athlete safe, which may include but are not limited to, removal from play, a brain rest period, a return to learn progression and graduated return to play progressions. I also understand that the ASHS Team Physician(s) and ASHS Certified Athletic Trainer(s) reserve the right to the last say in return to play decisions regarding concussions and athletic related injuries and/or illnesses. I acknowledge that in-season student-athletes take precedence over out-of-season student-athletes. I am also aware that any post-operative rehabilitation or injuries and/or illnesses requiring intensive rehabilitation may be out-sourced to local physical therapy clinics at the discretion of the Certified Athletic Trainer(s).
Required
OUTSIDE MEDICAL VISIT POLICY AGREEMENT *
Any visit to a Healthcare Provider [i.e. ER, PCP, Urgent Care, Specialist, PT, Chiropractor, etc.] regarding athletic related injuries [i.e. sprains/strains/contusions (bruises)/fractures (broken bones)/pain/brain injuries (concussion), etc.] and/or illnesses [i.e. mononucleosis, hospitalizations, anything other than your common cold/allergies/flu, etc.] outside of ASHS Team Physician(s) or Certified Athletic Trainer(s) will be communicated, and written documentation regarding diagnosis, diagnostics, prescribed treatment and participation/playing status/restrictions (if any) will be provided to the ASHS Certified Athletic Trainer(s) before resuming any/all ASHS sports-related activities [in-season or out-or-season workouts.] DO NOT hand this to a Coach/the athletic office/main office. Please present it directly, scan/email or fax to the Athletic Training Staff. This ASHS Athletic Department policy is non-negotiable. Failure to follow will result in delay returning to participation.
Required
CONCUSSION AWARENESS and POLICIES AGREEMENT - Student-athlete *
A concussion is a type of traumatic brain injury – or TBI – caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to bounce around or twist in the skull, stretching and damaging the brain cells and creating chemical changes in the brain. Medical providers may describe a concussion as a “mild” brain injury because concussion are usually not life-threatening. Even so, the effects of a concussion can be serious. Athletes with the signs and symptoms of a concussion should be removed from play immediately. Continuing to play with signs and symptoms of a concussion leaves the youth student-athlete especially vulnerable to greater injury. There is an increased risk of significant damage from a concussion for a period of time after the concussion occurs, particularly if the student-athlete suffers another concussion before completely recovering from the first. This can lead to prolonged recovery, or even severe brain swelling with devastating and even fatal consequences. It is well known that adolescent or teenage student-athletes will often under report symptoms of injuries, and concussions are no different. As a result, education of coaches, parents, and student-athletes is the key for student-athlete health and safety. Any student-athlete suspected of suffering a concussion should be removed from the game or practice immediately. No student-athlete may return to activity after an apparent or suspected head injury or concussion, regardless of how mild it seems or how quickly symptoms dissipate, without proper medical clearance.
Required
CONCUSSION AWARENESS and POLICIES AGREEMENT - Parent/Guardian *
A concussion is a type of traumatic brain injury – or TBI – caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to bounce around or twist in the skull, stretching and damaging the brain cells and creating chemical changes in the brain. Medical providers may describe a concussion as a “mild” brain injury because concussion are usually not life-threatening. Even so, the effects of a concussion can be serious. Athletes with the signs and symptoms of a concussion should be removed from play immediately. Continuing to play with signs and symptoms of a concussion leaves the youth student-athlete especially vulnerable to greater injury. There is an increased risk of significant damage from a concussion for a period of time after the concussion occurs, particularly if the student-athlete suffers another concussion before completely recovering from the first. This can lead to prolonged recovery, or even severe brain swelling with devastating and even fatal consequences. It is well known that adolescent or teenage student-athletes will often under report symptoms of injuries, and concussions are no different. As a result, education of coaches, parents, and student-athletes is the key for student-athlete health and safety. Any student-athlete suspected of suffering a concussion should be removed from the game or practice immediately. No student-athlete may return to activity after an apparent or suspected head injury or concussion, regardless of how mild it seems or how quickly symptoms dissipate, without proper medical clearance.
Required
CONSENT for EMERGENCY MEDICAL CARE and/or TRANSPORT - Parent/Guardian *
In the event that emergent care is necessary, I hereby grant permission to the ASHS Certified Athletic Trainer(s) to proceed with any medical or first-aid treatment for my student-athlete. In the event of serious illness, the need for major surgery or significant accidental injury, I understand that an attempt will be made to contact me in the most expeditious manner possible. If in the event I cannot be reached, the treatment necessary for the best interest of my student-athlete may be given. I have read the above statements and hereby give my written consent for my student-athlete to be transported to the nearest emergency room based on local EMS protocols to receive necessary treatment.
Required
ATHLETIC DEPARTMENT PARTICIPATION WAIVER *
I understand that the dangers and risks of participating in any sports include, but are not limited to: death, serious neck and/or spinal injuries, which may result in complete or partial paralysis, brain damage, serious injury to virtually all internal organs, other aspects of my body, general health and well-being. I understand that the dangers and risks of playing, practicing, or participating in any sport may result not only in serious injury, but in a serious impairment of my future abilities to earn a living, engage in other business, social or recreational activities, and generally to enjoy life. Because of the dangers of playing, practicing or participating in intramural or interscholastic athletic activity, I recognize the importance of following teachers’ and coaches’ instructions regarding playing techniques, training and other team rules, and agree to obey such instructions. In consideration of ASHS permitting me to engage in all activities related to the sport, including, but not limited to, trying out, playing, practicing or participating in that sport, I hereby voluntarily assume the risk of accident, injury or damage to person or property. Furthermore, I voluntarily release and discharge ASHS, its employees, agents, representatives, coaches, and volunteers from, without limitation, any and all actions, causes of action, claims, demands, damages, costs, expenses, compensation, and/or suits at law or in equity, on account of or relating to any act of omission by ASHS, its employees, agents, representatives, coaches or volunteers. I also agree to defend, indemnify and save ASHS harmless from and against any and all liability, actions, causes of action, debts, claims, or suits at law or in equity of any kind and nature whatsoever which may arise, directly or indirectly, by or in connection with my participation in any activity. The terms hereof shall serve as a release for my heirs, estate, executor, administrator, and assignees. I further acknowledge that if I am participating in football, rugby, cheerleading, wrestling, baseball, ice hockey, lacrosse, or soccer, I am aware that they are potentially violent collision or contact sports involving an even greater risk of injury than other sports. In addition, I acknowledge all the regulations and the potential of denial and dismissal from sport participation for violations of ASHS policy and/or the expectations and standards of the respective coach.
Required
RELEASE for HELMET SPORTS *
• Football: WARNING – Do not strike an opponent with any part of this helmet or facemask. This is a violation of football rules and may cause you or your opponent to suffer severe brain or neck injury. Severe brain or neck injury may also occur accidentally while playing football or lacrosse. No helmet can prevent all such injuries. You use this helmet at your own risk. I also understand that football and lacrosse are potentially injurious sports and agree to accept the risk of injury associated with competition in these sports. No helmet can prevent all such injuries. • Boys Lacrosse: WARNING – Do not use this helmet if the shell is cracked or deformed; or if the interior padding is deteriorated. Severe head or neck injury, including paralysis or death may occur to you despite using this helmet. No helmet can prevent all head injuries or any neck injuries a player might receive while participating in lacrosse. • Baseball and Softball: WARNING – Do not use this helmet if the shell is cracked or deformed; or if the interior padding is deteriorated. Severe head or neck injury, including paralysis or death may occur to you despite using the helmet. No helmet can prevent all head injuries or any neck injuries a player might receive while participating in baseball or softball. • Ice hockey: WARNING – No helmet can prevent all head or any neck injuries a player might receive while participating in hockey. Do not use this helmet to butt an opposing player. This is in violation of the hockey rules and such use can result in severe head or neck injuries, paralysis or death to you and possible injury to your opponent.
Required
AUTHORIZATION for RELEASE of MEDICAL RECORDS & PROTECTED HEALTH INFORMATION - Parent/Guardian *
I hereby authorize any healthcare provider involved in the care of my student-athlete, to release my student-athlete’s medical records which were generated based on our visit(s) to its facility for the purpose of medical examination, evaluation, and treatment to any Certified Athletic Trainer affiliated with ASHS. I understand that the release of my student-athlete’s medical information will be used for my student-athlete’s health and safety during the course of my student-athlete’s participation in athletics, and that the Certified Athletic Trainer(s) involved in my student-athlete’s care have been employed by ASHS as an approved medical provider. The medical records authorized for release include, but as not limited to all reports, findings, recommendations, test results, x-rays, other films, scans, slides, or any other information, documents or other items that concern my student-athlete’s medical condition, diagnosis, treatment, prognosis, or ability to participate in an organized athletic program. I understand that I may revoke this authorization at any time by notifying the Certified Athletic Trainer(s) involved in my student-athlete’s condition, which may ultimately delay my student-athlete’s return to athletic participation.
CONSENT for ADMINISTRATION of “OVER-THE-COUNTER” MEDICATIONS - Parent/Guardian *
I give permission to the ASHS Certified Athletic Trainer(s) to administer “over-the-counter” medication to my student-athlete through the standing orders provided by the supervising Team Physician(s). These medications may include, but are not limited to, brand or generic equivalent Tylenol, Advil, Motrin, cough drops, antacids, Benadryl, Hydrocortisone cream, Bacitracin or Neosporin. If my student-athlete has any “over-the-counter” or prescription known drug allergies, I have legibly indicated these on my student-athlete’s physical examination, Part I form.
MEDICAL INSURANCE RESPONSIBILITY AGREEMENT - Parent/Guardian *
I realize that as a part of ASHS athletics, my student-athlete may be injured despite the safety precautions taken by the school and the coaching staff. I am aware that ASHS urges that I provide medical insurance coverage for my child.
Required
As the parent/guardian, I attest that I have truthfully read and understand the information included on this form. *
Parent/Guardian: type your FULL name in the field below.
Your answer
As the student-athlete, I attest that I have truthfully read and understand the information included on this form. *
Student-athlete: type your FULL name in the field below.
Your answer
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