Sports Participation Packet | The Patrick School Online Forms

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*

Winter Sports*

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.

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