Eastchester HS Winter 2018 Athletic Participation Form
ALL FIELDS ARE REQUIRED
Permission to Participate
Sports Warning *
We are aware that playing or practicing any sport can be a dangerous activity involving MANY RISKS OF INJURY. We understand that the risks of engaging in sports include, 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 below 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
I give permission for my child to participate in the Eastchester School District Interscholastic Program and I have read the Eastchester “Student-Parent Athletic Handbook.” I have reviewed the student-parent athletic handbook with my child. It is my understanding that my child will comply with the established policies and procedures of Eastchester 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
Student Information
Student Last Name *
Your answer
Student First Name *
Your answer
Student Cell phone # *
Your answer
Student E-mail Address *
Your answer
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Winter Sport *
Grade *
EMERGENCY MEDICAL TREATMENT INFORMATION
In the event that I cannot be reached and my child requires emergency medical attention, I hereby grant permission for the emergency medical personnel contacted by the Eastchester Coaching Staff to attend my son/daughter. *
Required
Home Address *
Your answer
Town *
Your answer
Zip Code *
Your answer
State *
Your answer
Parent 1 Home Phone *
Your answer
Parent 1 Cell Phone *
Your answer
Parent Cell Phone 2 *
Your answer
Family Physician *
Your answer
Family Physician Phone *
Your answer
Emergency Contact Person *
Your answer
Emergency Contact Person Phone *
Your answer
Medical History and updates
The athlete is not cleared to participate until the physical exam date has been verified.
A record of your child's physical completed within one year of the start date of the sport must be on file in the health office. If it is not on file you may mail one in, hand one in or email it to AthleticApplication@eastchester.k12.ny.us
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 within 12 months prior to the start date of the sport. 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 state 'none'
Your answer
Epi-Pen *
Required
Asthma (including exercise induced) *
Required
Inhaler *
Required
Diabetes/Insulin pump *
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
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 indicate below if you agree to accept full responsibility for your child's well being while providing transportation to/from away competitions. I the Parent/Guardian, will be the responsible party for the trip to/from the school for an athletic event when needed. This will be in effect for the entire current sports season. I fully realize that in authorizing this procedure, I hereby remove the school from any liability and/or responsibility regarding travel during away athletic events while providing such transportation. *
Required
Advanced Athletic Placement (formally selection classification)
A 7th or 8th grader is NOT permitted to participate on a JV or a Varsity team. The only exception is to take the advanced athletic placement test and go through the full procedure. This includes a tanner rating done by a physician, a skill assessment done by the coach, and getting the 85% or higher for your child's age in 4 out of the 5 presidential fitness tests. Please contact the athletic office for more information.
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 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 Eastchester School District “EUFSD”, you understand and agree that EUFSD may store your information in a secure manner on its servers. EUFSD will utilize due diligence and prudent efforts to protect such information as would be considered good practice with regard to electronically stored data. EUFSD appreciates the importance of responsible use of this form and will not share it with any third party without express consent by you. If you choose to provide this form we will use the form only to complete the request specified in the 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
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