Athletic Parent Permission                                        

Sport:________________________

Name:_________________________Date Of Last Physical:____________Date of Birth:_________Grade:__________

Address:_______________________________Zip:__________Age:_____Sex:____Home Phone:__________________

Mother’s Name:_____________________Mother’s Work/Cell Number:______________________________________

Father’s Name:______________________Father’s Work/Cell Number:______________________________________

Physician:_____________________________Phone:______________________Fax:____________________________

Emergency Contact Information:   Name:________________Relationship:__________Phone(Circle one): Cell/Work/Home_______________

 

Directions: Please answer the following questions about your medical history. Explain “yes” answers at right of question.

Have you had or do you currently have any of the following conditions or events since your last exam?

 

.  1.a.  A sports physical for this year?

      b.  An injury or illness since your last exam?

c.  A chronic or ongoing illness (such as diabetes or asthma)?        

1.     Use prescription medicine to control asthma?

2.     Check here if carries an inhaler_____

d.  Any prescribed or o.t.c. medications that you take on a regular basis?

e.   Surgery, hospitalization or emergency room visits?

f.   Any allergies to medications? (list below)

g.  Any allergies to bee stings, pollen, latex or foods? (list below)

1.     Check here if carries epipen______

2.     Type of reaction:  rash, hives, or skin condition?

3.     Take  any medication for allergy symptoms?  (list below)

h.   Any anemia’s or blood disorders?

 2.  Any of the following head-related conditions:

     a.  Concussion requiring a physician’s evaluation?

           1.  How often and when? (answer below)

     b.  Memory loss or been knocked out?

     c.  A seizure?

     d.  Frequent or severe headache?

 3.  Any of the following heart related conditions:                                                                                                                                           

     a.  Chest pain?  When exercising?                                                                                                                                                                 

     b.  Heart murmur?       

     c.  High blood pressure or elevated cholesterol level? 

     d.  Restrictions from sports for heart problems?

     e.  Any family member or relative:                                                                                                                              

           1.  Died of a heart problem before age 35?

           2.  Died of a heart problem before age 50?

           3.  Died with no known reason?

           4.  Died while exercising?  During or after? (circle one)

           5.  With Marfan’s Syndrome?

 4.  Any of the following eye, ear, nose, mouth or throat conditions:

      a. Vision problems?

           1.  Wear contacts, eyeglasses or protective eyewear? (circle which type)

      b.   Hearing loss or problems?

            1.  Wear hearing aides or implants?

      c.   Nasal fractures or frequent nose bleeds?

      d.  Wear braces, retainer, or protective mouth gear?                                                                                      

      e.   Frequent strep or any other conditions of the throat (e.g. tonsils)?

 5.  Any of the following  neuromuscular/orthopedic conditions:

a.a burner, stinger, or pinched nerve?

          b. a sprain?

c. a strain?

          d. a swelling or pain in muscles, tendons, bones, or joints?

e. a dislocated joint?

           f. upper or lower back pain?

g. fracture or stress fracture?

          h. Do you wear any protective braces or equipment for any prior injury?

       .  6. Any of the following general or exercise-related conditions:

a. Difficulty breathing? During exercise? (circle one)

1. After running 1 mile?

2. Coughing, wheezing or shortness of breath in weather changes?

3. Been told you have exercise induced asthma?

                 i.     controlled with medication? (list below)

                ii.     experience dizziness, passing out or fainting?

2. Viral infections (e.g. mono, hepatitis)?

3. Become tired more quickly than your friends?

4. Any of the following skin conditions:

   1. acne, contact dermatitis, ringworm, warts, herpes?

   2. sun sensitivity?

5. Weight gain/loss (greater than or less than 10 pounds)

   1. Do you want to weigh more or less than you do now?

6. Ever had feeling of depression?

7. Heat-related problems (dehydration, dizziness, fatigue, headache)?

   1. Heat exhaustion? (cool, clammy, damp skin)

   2. Heat stroke? (hot, red, dry skin)

7.    Prior to attending Voorhees High School, have you ever participated in a Varsity Sport at another high school?

(Females ONLY)     8.  Age of onset of menstruation:_____ Date of last menstruation:_____________ Most number of days between menstruation cycles:_____

 *****

I hereby request to be enrolled as a candidate for the position on the_________________________team. 

                                                                                                                             Name sport

I agree to abide by the rules and regulations of Voorhees High School and assume all responsibilities for all equipment issued to me.

 

STUDENT SIGNATURE: ___________________________________________ DATE _______________________

 

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT

I hereby give permission for Emergency treatment by the team physician, school nurse, certified athletic trainer and allied medical personnel for conditions arising in athletics.  This may include, but not limited to, initial diagnostic x-ray and other procedures as the attending physician may deem necessary for the preservation of health.  I certify that if my child has sustained or incurred any injuries, illness or other health problems, which may affect participation in athletics since their last physical examination, it is duly reported in their “Athletic Medical History”.  I attest that this information is complete and accurate.  Realizing that athletic activity involves the potential of injury, which is inherent in all sports, I acknowledge that even with the best coaching, use of advanced protective equipment and strict observance of the rules, accidents are still a possibility.  On rare occasions the resultant injuries may be so severe that paralysis or even death may occur.  I agree to release this medical form to all necessary school personnel.  I have read and understand this warning and give permission for my son/daughter to participate.

 

SIGNATURE OF PARENT OR GUARDIAN: _________________________________DATE______________________