EMERGENCY/SPORTS PARENTAL PERMISSION FORM | | | | | SOUTHTOWNS CATHOLIC SCHOOL
2052 Lakeview Road P.O. Box 86
Lake View, New York 14085
TO: Parents/Guardians of Athletes
FROM: Judith M. MacDonald, Principal
RE: Emergency Information/Sports
Permission Form
Please answer ALL the following questions to help us provide the best possible care for your child in case of injury while participating in the interscholastic activities at Southtowns Catholic School. Include family physician and relative or friend who could be contacted when parents are not available.
He/she will be expected to attend all scheduled practices and games. I understand that I am responsible for transportation to and from practices and games. I understand that my son/daughter is responsible for all equipment/uniforms issued, and, if any of the equipment/uniforms issued are not returned in proper condition, I am liable for their replacement value.
Sincerely,
Mrs. Judith MacDonald, Principal
Name of Pupil: _______________________________________________ Grade: ___________
Has my permission to participate in: ___________________________for th schoolyear_______
Parent’s/Guardian Name:_________________________________________________
Home Address:__________________________Phone#:___________
Father’s Place of Employment: ______________________________ Phone #: ______________
Mother’s Place of Employment: ______________________________ Phone #: ______________
Friend/Relative (Emergency Contact): ________________________ Phone #: ______________
Physician: _________________________________________ Phone #: ______________
Emergency Numbers (cell phone, pager, etc.): ________________________________________
_____________________________________________________________________________
Authorization: In case of an emergency, if I cannot be reached, I authorize emergency treatment for my child, ____________________________________________________, including treatment by a doctor other than our physician.
Parent/Guardian signature ___________________________________Date: ________________
A consolidated school of Our Lady of Perpetual Help & St. Vincent de Paul parishes. | | | Parent Consent & Health Office Update Questionnaire Form | | | | | SOUTHTOWNS CATHOLIC SCHOOL
PARENT CONSENT & HEALTH OFFICE UPDATE QUESTIONNAIRE FORM
Prior to the start of tryout sessions or practice at the beginning of each season, a health history review for each athlete must be conducted unless the student received a full medical examination within 30 days of the start of the season.
Name _________________________________Birth Date __________Grade ___ Gender M F
Address_______________________________Phone #____________ SPORT______________
Date of last approved sports physical __________________ by __________________________
Since your child’s last sport physical, has he/she had any of the following?
INTEVAL MEDICAL HISTORY
Any injuries lasting 5 or more days requiring medical attention? YES NO
Taking medicine or under physician’s care at this time? YES NO
Any feeling of faintness, dizziness, fatigue after heavy exertion? YES NO
Any surgery, broken bones, concussion or treated in an ER? YES NO
Any known allergies or chronic disease? YES NO
Any change in wearing glasses or contact lenses? YES NO
____________________________________________________________________________
PARENTS MUST NOTIFY THE SCHOOL OF ANY CHANGE IN CHILD’S MEDICAL STATUS.
We have carefully read, understand, and agree to abide by the rules and regulations set by Southtowns Catholic School. To the best of our knowledge, there is no physical condition that would exclude the above named athlete from participation.
Student Signature: ____________________________________________________
Parent/Guardian Signature: _____________________________________________
The above named student is physically qualified to participate in __________________________
Restrictions: ___________________________________________________________________
School Nurse: _______________________________________________ DATE: ____________
PAGE 1 | | | Sports Candidate Questionnaire | | | | | SOUTHTOWNS CATHOLIC SCHOOL
Sports Candidates Questionnaire>
THIS FORM MUST BE COMPLETED & RETURNED TO THE HEALTH OFFICE AS SOON AS POSSIBLE
NAME: ______________________________________ Medical Coverage? Yes NO
Birth Date: ___________________________________ Name if Insurance Company: ________________
Age: __________ Gender: M F (circle)
Has your child ever had: (Please circle) Yes(Y)No (N)
Allergies/Hay Fever (Y) (N
Bee Sting Allergy (Y) (N
Asthma (Y) (N)
Anemia (Y) (N)
Arthritis Y) (N)
Bladder/Kidney/Problem or Injury (Y) (N)
Convulsions (Y) (N)
Fainting Spells (Y) (N)
Diabetes (Y) (N)
Ear Problems/Hearing Loss (Y) (N)
Eye Problems/Vision Loss (Y) (N)
Injury to the Spleen (Y) (N)
Joint/Ligament Tear/Muscle Pull (Y) (N)
Wears Contacts/Glasses (Y) (N)
Elevated Blood Pressure (Y) (N)
Headaches (Y) (N)
Head Injury/Concussion (Y) (N)
Heart Problem/Murmur-Chest Pain (Y) (N)
Nose Bleeds/Frequent-Severe (Y) (N)
Ankle Injury (Y) (N)
Back Pain/Injury (Y) (N)
Fracture-Dislocation Bones/Joints (Y) (N)
Knee Pain/Injury (Y) (N)
Neck Injury (Y) (N)
Nose Fracture (Y) (N)
Rheumatic Fever (Y) (N)
Stomach Ulcer (Y) (N)
Surgical Operation (Y) (N)
Is your child missing any paired Organs and/or transplants (Eyes, ears, testicles, lungs, kidneys)? (Y) (N)
Has your child ever had an illness within the past year since last physical requiring medical attention which may hinder sports participation. (Diabetes, Hyperactivity, Surgery, etc)? (Y) (N)
Has your child taken any medicine in the past year? (Y) (N)
Is your child taking medication now? (Y) (N)
Has your child fainted during exercise? (Y) (N)
If you have checked “YES” to any of the above, explain:_________________________________________
I, the undersigned, clearly understand these questions are asked in order to decide if my child can safely participate on the athletic team named on Page 1 of this form. The answers are correct of this date and he/she has my permission to participate.
Parent/GuardianSignature:_____________________________
Date: _________________________________________
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