IESA - Emergency Information Form - Athletics and Activities
Coaches and sponsors carry this with them at all events in case the parent/guardian is not able to attend and there is an emergency. You are limited to 1 response per email address. If you have multiple children please enter all on 1 form.
Email address *
Student(s) Name *
I verify that I am the parent or guardian of the above listed student and take responsibility for the information given. *
Required
Current grade level *
Parent/Guardian Name *
Emergency Contact Number *
2nd Emergency Contact Number *
Physician Name *
Physician Number *
Specific health Conditions (if any. if none please list n/a) Asthma, heart conditions, etc... *
If you and the physician of choice (as indicated above) can not be reached in case of an emergency and if, in the judgement for the school authorities, immediate medical and/or hospital attention is indicated, do you authorize responsible school authorities to send your child (properly accompanied) to an available hospital or physician? *
Required
Insurance Information. As the parent/guardian, I wave any claim for liability against the Athletic Co-op, including employees and representatives, and release them from liability in connection with this activity. *
Required
Insurance Carrier *
Policy Number *
IESA - Concussion Information Sheet.
CONCUSSION INFORMATION SHEET

A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force transmitted to the head. They can range from mild to severe and can disrupt the way the brain normally works. Even though most concussion are mild, all concussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and managed properly. In other words, even a "ding" or a bump on the head can be serious. You can't see a concussion and most sports concussions occur without loss of consciousness. Signs and symptoms of concussion may show up right after the injury or can take hours or days to fully appear. If your child reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself, seek medical attention right away.

Symptoms may include one or more of the following:

*Headaches *Amnesia *Pressure in head *Don't feel right *Nausea or vomiting *fatigue or low energy *neck pain *sadness *balance problems or dizziness *nervousness or anxiety *blurred, double, or fuzzy vision *irritability *sensitivity to light or noise *more emotional *feeling sluggish or slowed down *confusion *feeling foggy or groggy *concentration or memory problems (forgetting game plays) *drowsiness *change in sleep patterns *repeating the same question/comment

Signs observed by teammates, parents and coaches include:

*Appears dazed *Vacant facial expression *confused about assignment *forgets play *is unsure of game, score, or opponent * moves clumsily or displays in-coordination *answers questions slowly *slurred speech * shows behavior or personality changes *can't recall events prior to hit *can't recall events after hit * seizures or convulsions *any change in typical behavior or personality *loses consciousness

What can happen if my child keeps on playing with a concussion or returns too soon?
Athletes with the signs and symptoms of concussion should be removed from play immediately. Continuing to play with the signs and symptoms of a concussion leaves the young 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 athlete suffers another concussion before completely recovering from the first one. This can lead to prolonged recovery, or even to severe brain swelling (second impact syndrome) with devastating and even fatal consequences. It is well known that the adolescent or teenage athletes will often fail to report symptoms of injuries. Concussions are no different, as a result, education of administrators, coaches parents and students is the key to student-athlete's safety.

If you think your child has suffered a concussion.
Any athlete even suspected of suffering a concussion should be removed from the game or practice immediately. No athlete may return to activity after an apparent head injury or concussion, regardless of how mild it seems or how quickly symptoms clear, without medical clearance. Close observation of the athlete should continue for several hours. IESA and IHSA policy requires to provide their school with written clearance from either a physician licensed to practice medicine in all its branches or a certified athletic trainer working in conjunction with a physician licensed to practice medicine in all its branches prior to returning to play or practice following a concussion or after being removed from an interscholastic contest due to a possible head injury or concussion and not cleared to return to that same contest. In accordance with state law, all IHSA member schools are required to follow this policy. You should always inform your child's coach if you think that your child may have a concussion. Remember its better to miss one game than miss the whole season. And when in doubt, the athlete sits out.

Student/Parent Consent and Acknowledgements. By clicking the box below, we acknowledge we have been provided information regarding concussion and the IHSA Performance-Enhancing Testing Policy. We also acknowledge that we are providing consent to be tested in accordance with the procedures outlined in the IHSA Performance-Enhancing testing Policy. *
Required
Permission to Participate Form and Handbook acceptance
By checking yes on the upcoming questions you agree to allow your child to participate in the schools activities or sporting teams/clubs. You also agree to the athletic regulations and terms that are printed in the schools handbook which is available upon request.
As the parent/guardian, I give my son/daughter permission to participate in sports/activities and understand the handbook guidelines. *
Required
As the student/athlete, I understand that I am representing Hamilton Junior High School and I agree to conduct myself at all times in accordance with the handbook guidelines. *
Required
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This form was created inside of Hamilton High School CCSD # 328. - Terms of Service - Additional Terms