Sports Sign Up
This form will guide you through the necessary process to have your child participate in sports at W. F Kaynor Techinical High School.. A sports physical must be approved by the school nurse and a signed permission slip must be on file with your coach.

This electronic form should be completed with the student and the parent/guardian together, as the concussion information is extremely important and should be discussed as a family unit.

If you have any questions, please email Kathryn.Patrick@ct.gov or call 203-578-8790.

Thank-you,

Kathryn Patrick, Athletic Director

PLEASE REVIEW THIS LINK BEFORE COMPLETING THE FORM: DO NOT TAKE THE QUIZ ON THE LINK! YOU MUST COME BACK TO THIS PAGE, SCROLL DOWN PAST THE KAYNOR LOGO AND THEN TAKE THE QUIZ AND DO THE SIGN OFF FROM THIS PAGE!

https://sites.google.com/a/cthss.org/concussion/1-instructions


DO NOT TAKE THE QUIZ ON THE LINK! YOU MUST COME BACK TO THIS PAGE, SCROLL DOWN PAST THE KAYNOR LOGO AND THEN TAKE THE QUIZ AND DO THE SIGN OFF FROM THIS PAGE!
Student Last Name
Your answer
Student First Name
Your answer
Parent/Guardian Last Name
Your answer
Parent/Guardian First Name
Your answer
Parent/Guardian email:
Your answer
As the parent/guardian, I have reviewed the District Concussion Training Link Above, including the video, with my child and if I have any questions, I will contact the W. F. Kaynor Technical High School nurse, athletic director, or coach at 203-596-4302
As a student athlete, I have reviewed the District Concussion Training Link Above, and the video with my parent/guardian and if I have any questions, I will contact the W. F. Kaynor Technical High School nurse, athletic director, or coach at 203-596-4302
Sport child will participate in
Grade
Please review the Student Athlete Handbook at the following link https://docs.google.com/document/d/1bhA6VOBAMiFMY2ELa0ngz-iWXteZhxE19z3Ab9K7y1A/edit?usp=sharing As the parent/guardian, I have read the Kaynor Tech Athlete Handbook. I am aware that the student handbook for the CTHSS is also in effect. I understand that if these policies, or the policies of the coaching staff, are not followed by the athlete, the athlete may face discipline or consequences up to and including being removed from the team/program. (Type first and last name)
Your answer
As the student athlete, I have read the Kaynor Tech Athlete Handbook. I am aware that the student handbook for the CTHSS is also in effect. I understand that if these policies, or the policies of the coaching staff, are not followed by the athlete, the athlete may face discipline or consequences up to and including being removed from the team/program. (Type first and last name)
Your answer
Review the Concussion Signs/Symptoms, and Return to Play (RTP) protocol
Student Electronic Signature and Date for concussion protocol acknowledgement:
Your answer
Parent Electronic Signature and Date for concussion protocol acknowledgement:
Your answer
Please Review the Sudden Cardiac Arrest Symptoms/Signs and Return to Play (RTP) Protocol per the CIAC below
Student Electronic Signature and Date for sudden cardiac arrest protocol acknowledgement:
Your answer
Parent Electronic Signature and Date for sudden cardiac arrest protocol acknowledgement:
Your answer
PARENT/GUARDIAN CONCUSSION QUIZ - Please take the District Concussion Quiz Below. The CIAC Requires this for every sport season. I certify that my child and his parent/guardian are taking this quiz together and if there are any questions, we will contact the school nurse, athletic director, or coach. The district requires that the parent/guardian and student must both take the concussion quiz
Your answer
Parent Response- A concussion is a brain injury
Parent Response - Only concussions that occur in school must be reported to the school nurse
Parent Response - Which of these is NOT a sign of concussion following a blow or bump to the head
Parent Response - A student with a concussion may not return to school, trade/technology, sports, or physical education class until he/she has approval from a doctor or health care professional.
Parent Response - Concussion can only happen is the student has been knocked out or has lost consciousness
Parent Response - A repeat concussion that occurs before the brain recovers from the first concussion can slow recovery or increase the likelihood of having long-term problems
Parent Response - Concussion can only happen to a student who plays sports
Parent Response - You cannot see a concussion and some students with concussions may not experience or report symptoms until hours or days after a head injury
Parent Response - Following a coach's rules for safety and the rules of the sport, practicing good sportsmanship at all times and using proper sports equipment are all ways to help prevent a concussion
Parent Response - Can a student who is complaining of a headache following a blow or hit to the head return to sports, practice, or play on the same day?
Student Response - A concussion is a brain injury
Student Response - Only concussions that occur in school must be reported to the school nurse
Student Response - Which of these is NOT a sign of concussion following a blow or bump to the head
Student Response - A student with a concussion may not return to school, trade/technology, sports, or physical education class until he/she has approval from a doctor or health care professional.
Student Response - Concussion can only happen is the student has been knocked out or has lost consciousness
Student Response - A repeat concussion that occurs before the brain recovers from the first concussion can slow recovery or increase the likelihood of having long-term problems
Student Response - Concussion can only happen to a student who plays sports
Student Response - You cannot see a concussion and some students with concussions may not experience or report symptoms until hours or days after a head injury
Student Response - Following a coach's rules for safety and the rules of the sport, practicing good sportsmanship at all times and using proper sports equipment are all ways to help prevent a concussion
Student Response - Can a student who is complaining of a headache following a blow or hit to the head return to sports, practice, or play on the same day?
By signing my name below, I certify that I have completed the CTHSS Concussion Training and Video. (type first and last name of parent/guardian)
Your answer
By signing my name below, I certify that I have completed the CTHSS Concussion Training and Video. (type first and last name of student athlete)
Your answer
As the parent/guardian, I recognize the need for prompt evaluation of the signs and symptoms of a concussion following a head injury
As the student-athlete, I recognize the need for prompt evaluation of the signs and symptoms of a concussion following a head injury
As a parent/guardian, I recognize that all sports (interscholastic, inter-mural, and club) pose some risk of concussion
As a student-athlete, I recognize that all sports (interscholastic, inter-mural, and club) pose some risk of concussion
As a parent/guardian, it is my responsibility to review my child's physical expiration date and obtain a new physical if needed. The physical expiration date is listed on the permission slip
Please enter todays date:
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