High School - East Hartford High School



PARENT PERMISSION FORM FOR PARTICIPATION IN ATHLETIC PROGRAMSI give my son/daughter permission to play any and all sports during the current school year. Students may change their sport choice throughout the course of the year.Student Name: ____________________________________________Grade: ____________Address: ______________________________ Zip: __________ Home Phone: ______________Cell: _________________ Date of Birth: _____________ Family Physician: _________________Physician Phone: ________________________ Hospital Preference: ______________________School: EHHS_____CIBA _____Synergy _____ Other: _____________________________If a parent cannot be reached, the alternative emergency contact is:Emergency Contact 1: _________________________ Relation: __________________________Home Phone:__________________________ Cell: ____________________________________Emergency Contact 2: _________________________ Relation: __________________________Home Phone:__________________________ Cell: ____________________________________Fall Sports Choice: ______________________________________________________________Winter Sport Choice: ____________________________________________________________Spring Sport Choice: _____________________________________________________________I understand that my child will not be allowed to practice or participate until they have completed this form, have a current physical completed, and have submitted concussion and cardiac arrest consent forms. _____________________________________________________________________________________________Restriction: Any operation, serious accident, long-term illnesses will require a private physician’s certificate granting the student-athlete permission to participate. I hereby give permission for the above student to participate in organized middle/high school athletics, as part of the inter-scholastic/intramural program. I realize that such activity involves the potential for injury which is inherent in all sports. I acknowledge that even with the best coaching, use of the most advanced protective equipment and strict observance of rules, injuries are still a possibility. On rare occasions, these injuries can be so severe as to result in total disability, paralysis or even death. I also declare that the above student has not received any previous physical injury and has no physical disability which may be jeopardized or aggravated by the sport in which he/she is allowed to participate. ___________________________________________________________________________________________________________________It is my understanding that the above student is covered by an athletic accident insurance policy purchased by the East Hartford Board of Education that agrees to pay medical costs not covered by my own insurance. It is further understood that in the event the above student is hospitalized as a result of an injury, I will provide the hospital admitting office with my insurance plan number. If physical therapy is required I understand that is a monetary limit (presently $500) per injury.___________________________________________________________________________________________________________________I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND BOTH SIDES AND COMPLY WITH ALL THE REGULATIONS SET FORTH. PARENT/GUARDIAN SIGNATURE: __________________________________________DATE: _______________-114300277495OFFICE USE ONLY:DATE OF PHYSICAL: _________FALL ______ WINTER_______ SPRING______CONSENT FORMS ON FILE: CONCUSSION: F W S CARDIAC: F W S00OFFICE USE ONLY:DATE OF PHYSICAL: _________FALL ______ WINTER_______ SPRING______CONSENT FORMS ON FILE: CONCUSSION: F W S CARDIAC: F W SSTUDENT-ATHLETE SIGNATURE: ___________________________________________ DATE: _______________PARENT PERMISSION FORM FOR PARTICIPATION IN ATHLETIC PROGRAMSPHYSICAL EXAM MUST NOT BE GREATER THAN THIRTEEN MONTHS OLDER THAN THE START OF THE SEASON!#DescriptionYESNO1Have you had a medical illness or injury since your last check up or sports physical?2Has a physician ever denied or restricted your participation in sports for any problems?3Have you ever had surgery?4Are you currently taking any prescription or non-prescription (over the counter) medication or pills including vitamins?5Do you have asthma?6Do you use an inhaler?7Do you have any allergies (for example, to pollen, medicine, food or stinging insects)?8Do you use an epi-pen?9Have you ever passed out during or after exercise?10Have you ever had chest pain or heart racing during or after exercise?11Have you had high blood pressure or high cholesterol?12Have you ever been told you have a heart murmur?13Do you have any skin problems (for example, itching, rashes, acne, warts, fungus, blisters, or ringworm)?14Have you ever had a head injury or concussion?15Have you ever had a seizure?16Have you ever had numbness or tingling in your arms, hands, legs, or feet?17Do you use any special protective or corrective equipment or devices (for example, knee brace, retainer on teeth, hearing aid, etc.)?18Have you ever had a sprain, strain, swelling, or fracture after an injury?19Do you wear glasses, contacts, or protective eyewear?If you responded ‘yes’ above please explain below:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ................
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