MPH Boys Lax

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 Manlius Pebble Hill School Health History and Consent Form for Sports Participation

 

At the beginning of each sports season, prior to the start of the first practice, a health history review for each athlete must be conducted. Every participant on the team must complete this form and give it to the nurse prior to the first practice. Failure to turn in this form, without exception, will result in ineligibility for participation. Front and back must be completed.

 

SPORT________________         FALL______     WINTER______   SPRING_______

 

Grade________    Coach(es)________________________________________________

 

STUDENT'S NAME    ___________________________________________________

 

Birth date____________ Age____

 

Parent  Full Name (contact first)	Home Phone
	Work Phone
	Cell Phone
	Beeper
Parent Full Name	Home Phone
	Work Phone
	Cell Phone
	Beeper
Guardian Full Name	Home Phone
	Work Phone
	Cell Phone
	Beeper

Alternate person to be responsible for student if parent/guardian cannot be reached in an emergency_________________________________________________________________

Name of Insurance Company and Policy Holder_________________________________

 

Policy #                                    Group #                             Phone # __________________

                                                                                                (if authorization is needed)

Allergies________________________________________________________________

 

Current medications your child is taking ____________________________________________

Date of last tetanus _________________________

 

Healthcare Provider and # _________________________________________________

                                                                                                Name___________________

HISTORY SINCE LAST FULL PHYSICAL:

 

1. Any injuries or illness requiring loss of school or practice for more than 5 days, or required hospitalization?

______________________________________________________________________

2. Any treatment in a hospital or emergency room?______________________________

3. Under a doctor's care at this time___________________________________________

 

4.. Any feeling of faintness, dizziness, fatigue after exercise or exertion, or unconsciousness?

________________________________________________________________________

5. Had a concussion or a seizure?_____________________________________________

6. Any chronic illnesses such as hypertension, asthma, or diabetes?_________________________

7. Does your child wear corrective lenses/contact lenses? ________________________

8. Have any family members had a heart attack under age 50, or died unexpectedly?____________

Additional comments______________________________________________________

________________________________________________________________________

 I understand that transportation to and from off-campus games will be

 

provided by means of _______________________.

 (Bus/Van/Car)

 

My child has permission to play this sport.  I understand that this sport is voluntary and that there are some risks involved with playing this sport, including traveling to and from the location to attend games, and I am willing to accept those risks.  In addition, I will not hold Manlius Pebble Hill (“MPH”) accountable for the acts of third parties, such as, but not limited to, common-carriers or vendors.  In the event of illness or injury, I expect to be consulted immediately, but in the event that consultation is not possible, I hereby consent to whatever treatment is necessary in the best judgment of MPH, and any attending physician and/or dentist and/or hospital and/or facility furnishing medical or dental services.  Accordingly, I absolve and hold harmless MPH with regard to any and all liability relating to said treatment.  Further, I understand that I am responsible for providing the primary medical insurance for my child and for any payment of any medical expenses for my child that are incurred and not covered by any additional insurance.

 

DATE:  ______                    _______________________________(Signature of Parent or Guardian

 

___________________________________________________________________________________________________________

For Nurse use:

 

Date of Last Physical recorded in Health Office:  _______________________

 

 

Cleared by nurse: ________________________________________________________________     Date: