Sports Participation Packet | The Patrick School Online Forms

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STUDENT & EMERGENCY MEDICAL PROFILE INFORMATION
Your son/daughter has requested the privilege of taking part in our athletic program. Before he/she may take part, it is necessary for us to have your consent by completing the forms included in this packet.
School (for the 2019-2020 school year)*
Fall Sports*
- Cheerleading
- Cross Country (B)
- Cross Country (G)
- Football
- Soccer (B)
- Soccer (G)
- Tennis (G)
- Volleyball
Winter Sports*
- Basketball (B)
- Basketball (G)
- Cheerleading
- Ice Hockey
- Swimming
- Winter Track (B)
- Winter Track (G)
- Wrestling
Spring Sports
- Baseball
- Softball
- Spring Track
- Boys Tennis
Level:*
- Varsity
- Junior Varsiy
- Freshmen
Student-Athlete First Name*
Student-Athlete Last Name*
Gender*
Student Email*
Grade (for the 2019-2020 school year)*
Student Age*
Date of Birth*
Home Phone*
STUDENT ADDRESS
Street*
City*
State*
Zip*
Parent/Guardian/Emergency Contact Information
Parent-Guardian #1 First Name*
Parent-Guardian #1 Last Name*
Parent-Guardian #1 Email*
Work Phone*
Cell Phone*
Parent-Guardian #2 First Name
Parent-Guardian #2 Last Name
Parent #2 Email
Work Phone
Cell Phone
Alt. Contact #1 First Name*
Alt. Contact #1 Last Name*
Relationship*
Work Phone*
Alt. Contact #2 First Name
Alt. Contact #2 Last Name
Relationship
Work Phone
Physician/Medical Information
Physician First Name*
Physician Last Name*
Phone*
Fax
Physician Street*
Physician City*
Physician State*
Physician Zip*
Dentist First Name*
Dentist Last Name*
Phone*
Dentist Street*
Dentist City*
Dentist State*
Dentist Zip*
Known Allergies- medicines, insects, et...*
Write 'none' if you do not have any allergies.
Does your child wear glasses?*
- Yes
- No
Does your child wear contacts?*
- Yes
- No
Medications taken if any:*
Medical Conditions-Previous Injuries*
List any operations or illnesses your child has had since his last physical.
Medical Insurance Name:*
Preferred Hospital:*
Date of Last Tetnus:*
IMMUNIZATION INFORMATION

DPT-DT-DtaP-Td-Tdap*

1st Dose	2nd Dose	3rd Dose	4th Dose	5th Dose

DPT/HIB*

1st Dose	2nd Dose	3rd Dose	4th Dose	5th Dose

Polio*

1st Dose	2nd Dose	3rd Dose	4th Dose	5th Dose

MMR*

1st Dose	2nd Dose	3rd Dose	4th Dose	5th Dose

HIB*

1st Dose	2nd Dose	3rd Dose	4th Dose	5th Dose

Hepatitis B (3 Doses)*

1st Dose	2nd Dose	3rd Dose

Hepatitis A (2 Doses)*

1st Dose	2nd Dose

Gardasil (HPV 3 Doses)*

1st Dose	2nd Dose	3rd Dose

Prevnar*

1st Dose	2nd Dose	3rd Dose	4th Dose	5th Dose

Varicella*

1st Dose	2nd Dose	3rd Dose	4th Dose	5th Dose

Flu*

1st Dose	2nd Dose	3rd Dose	4th Dose	5th Dose

Menactra (1dose)*

1st Dose

PARENTAL CONSENT
Transportation for away games is provided by volunteer drivers. Are you available to help with transportation to away games?*
- Yes- I am available for transportation to away games
- No- I am not available for transportation to away games
The team physician, trainer and coach may apply first aid treatment until the family doctor can be contacted.*
- Yes
- No
We give our consent for team physician, trainer and coaches to use their own judgement in securing medical aid and ambulance service in case the parents cannot be reached.*
- Yes
- No
Parental Consent*
- In order to participate in Interscholastic Sports, a student must have this fonn completed prior to the first day of practice. The Medical History Questionnaire and Medical Index Card are to be completed by your parent/guardian. The physical examination section must be completed by the school physician or your family doctor. Each candidate for a place on a school athletic team shall be given a medical examination by the medical inspector or designated team doctor no more than 60 days prior to the first practice session, or in lieu thereof, the medical inspector may accept the report of such an examination by a physician licensed to practice medicine. Each candidate must undergo one medical examination in each school year. A medical re-evaluation shall be given to every athlete who has been previously injured in any sport and intends to participate in the following seasonal sport activity.
  
  Realizing that such activities involves the possibility for injury in all sports, I/we acknowledge that even with the best coaching, use of the most protective equipment, and strict observance of the rules, injuries are still a possibility. On rare occasions these injuries can be so severe that total disability or paralysis or even death may occur. I/we acknowledge this fact and have an understanding of this warning. With this in mind, I/we give permission for the above named athlete to participate in inter-scholastic athletics at The Patrick School.
STUDENT CONSENT
Student Consent*
- I understand that in order to participate, I must:
  1. Have on file in the Athletic Department Office a Consent Form signed by my parent or guardian, giving his/her approval.
  2. Have a completed Emergency Information for Athletic Participants Card on file in the office of the Athletic Trainer.
  3. Pass a comprehensive physical examination given by the school physician.
  4. Be eligible according to New Jersey Interscholastic Athletic Association, our affiliated league and The Patrick School rules, i.e. academic attendance and disciplinary rules.
  5. Agree to obey all regulations pertaining to the practice periods and squad rules as established by the coaches and to conduct myself in a courteous manner both on and off the field, track and/or court at all times.
  6. Be responsible for knowing special regulations and penalties for violation of school rules concerning athletics.
  7. Be responsible for the care of and safe return of all school equipment issued to me and to pay for equipment damaged or not returned at the original cost of said equipment.

NJSIAA Concussion Policy Acknowledgement Form
In order to help protect the student-athletes of New Jersey, the State of New Jersey and the NJSIAA have mandated that The Patrick School, and all student-athletes, parents/guardians and coaches follow the Concussion Management Policy.

For up-to-date information on concussions, you can go to:
Concussions In Youth Sports or NFHS Learn.
Please click all confirming you have read and understand the Concussion Acknowledgment Form*
- I have read the Concussion Acknowledgment

NJSIAA Steroid Testing Policy Consent To Random Testing
In Executive Order 72, issued December 20, 2005, Governor Richard Codey directed the New Jersey Department of Education to work in conjunction with the New Jersey State Interscholastic Athletic Association (NJSIAA) to develop and implement a program of random testing for steroids, of teams and individuals qualifying for championship games.

Beginning in the Fall, 2006 sports season, any student-athlete who possesses, distributes, ingests or otherwise uses any of the banned substances on the attached page, without written prescription by a fully-licensed physician, as recognized by the American Medical Association, to treat a medical condition, violates the NJSIAA’s sportsmanship rule, and is subject to NJSIAA penalties, including ineligibility from competition. The NJSIAA will test certain randomly selected individuals and teams that qualify for a state championship tournament or state championship competition for banned substances. The results of all tests shall be considered confidential and shall only be disclosed to the student, his or her parents, and his or her school. No student may participate in NJSIAA competition unless the student and the student’s parent/guardian consent to random testing.

By signing below, we consent to random testing in accordance with the NJSIAA steroid testing policy. We understand that if the student or the student’s team qualifies for a state championship tournament or state championship competition, the student may be subject to testing for banned substances.
Please click the box below confirming your have read the List of Banned Substances*
- I have read the List of Banned Substances
Please click the box below confirming your have read the Steroid Testing Policy*
- I have read the Steroid Testing Policy
Digital Signature*
- By clicking this box, both student/athlete and parent/guardian attest to our understanding and concurrence with the information presented on this page.

Sudden Cardiac Death in Young Athletes
All student-athletes and their parents need to read and become familiar with the Sudden Cardiac Death in Young Athletes brochure.
Please click the box below confirming your have read the Sudden Cardiac Death in Young Athletes Brochure*
- I have read the Sudden Cardiac Death in Young Athletes Brochure

Step 1 of 7

STUDENT & EMERGENCY MEDICAL PROFILE INFORMATION

STUDENT ADDRESS

Parent/Guardian/Emergency Contact Information

Physician/Medical Information

IMMUNIZATION INFORMATION

PARENTAL CONSENT

STUDENT CONSENT

NJSIAA Concussion Policy Acknowledgement Form

NJSIAA Steroid Testing Policy Consent To Random Testing

Sudden Cardiac Death in Young Athletes

HEALTH HISTORY UPDATE

PREPARTICIPATION PHYSICAL EVALUATION

Declaration