HCC Spring 2017 Athletic Participation Form
ALL FIELDS ARE REQUIRED
Permission to Participate
I give permission for my child to participate in the Byram Hills School District Interscholastic Program and I have read the Byram Hills “Student-Parent Athletic Handbook.” It is my understanding that my child will comply with the established policies and procedures of Byram Hills 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. We therefore expressly agree to obey all of the coach’s instructions and warnings. It is acknowledged that we have read and understand the implications of this sports warning.
Required
Student Information
Student Last Name *
Your answer
Student First Name *
Your answer
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Spring 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 Byram Hills Coaching Staff to attend my son/daughter in an appropriate medical setting. *
Required
Parent 1 Home Phone *
Your answer
Parent 1 Cell Phone *
Your answer
Parent Home Phone 2 *
Your answer
Parent Cell Phone 2 *
Your answer
Family Physician *
Your answer
Family Physician Phone *
Your answer
Family Dentist *
Your answer
Family Dentist Phone *
Your answer
Emergency Contact Person *
Your answer
Emergency Contact Person Phone *
Your answer
Medical History and Update
The athlete is not cleared to participate until the physical exam date has been verified.
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. Unless the physical examination has been conducted within the past 30 days of the start of a season, a health history up-date is required.
Your answer
List any allergies *
if none, please click 'none
Listing of Allergies
Please list allergies you said yes to in prior question.
Your answer
Epi-Pen *
Required
Asthma (including exercise induced) *
Required
Inhaler *
Required
Diabetes *
Required
Seizures *
Required
Is your child taking any medicine or performing enhancing substances or under a physician's care at this time? *
Required
If yes, please list any current medications. If no, state 'none' *
Your answer
Has your child had any injuries, including head injuries/concussions requiring medical attention? *
Required
Does your child have any heart/circulatory conditions, or has he/she had any feelings of faintness, dizziness or fatigue after exercise or exertion? *
Required
Has your child had any communicable diseases in the past year? *
Required
Has your child had any treatment in a hospital or emergency room this past year? *
Required
Has your child had any illness lasting more than five (5) days this past year? *
Required
Any changes in your child's glasses or contacts during the past year? *
Required
Has your child had any surgical operations, organ removal or fractures in the past year? *
Required
Does your child have a chronic disease? *
Required
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 Byram Hills School District. 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 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
Required
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
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 read the http://www.byramhills.org/files/filesystem/Trans_Waiver_Release-A-Rev0110.pdf Transportation A Signoff and indicate below if you agree to accept full responsibility for your child's well being while providing such transportation. *
Required
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 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.
Type your full name *
Your answer
Parent/Contact Person Email Address *
Please put an email address so if there are any questions, we can contact you.
Your answer
Please email or fax a copy of your child's current physical to: Deborah Negrin (dnegrin@byramhills.net) or fax # (914) 273 - 7275
Please hit the submit button ONLY ONCE, then wait for a message confirming your submission before exiting.
Submit
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