Download emergency contact information

Nauset Regional High School
Athletic Department
PO Box 1887
North Eastham, MA 02651
For Office Use Only
Date to Athletic Office: ____________ Physical Date: ________________
Impact Date: ___________________ Parent Meeting: _______________
PHYSICAL DATE MUST BE AFTER: July 20th, 2011
RETURN BY: August 1st, 2012
ImPACT Testing Dates: Middle School; May 30th & 31st/High School; June 6th & 7th
PLEASE CIRCLE ONE SPORT:
BOYS:
FOOTBALL
SOCCER
GIRLS:
FIELD HOCKEY
SOCCER
COED:
CREW
CROSS COUNTRY
CROSS COUNTRY
GOLF
VOLLEYBALL
CHEER
EMERGENCY CONTACT INFORMATION
This form is to be used by the athletic trainer or EMT on site, in the event of an emergency when you cannot be
reached. Please complete, sign, and return this form to the school prior to the first practice of the athletic season.
Student’s Name: ___________________________________ Birthdate: ____________ SS#: _____________
Year of Graduation: _______________ Parent’s Name: _______________________________________
Address: _______________________________________ City: ______________ Zip Code: _________
Phone #: ______________________ Work #: _______________________ Cell #: ______________________
Parent E-Mail Address: _____________________________________
Student Email: ____________________________________________
In Case of an Emergency Contact: __________________________ Phone #:_______________________
(Other than Parent or Guardian)
Insurance Group: _________________________________
Policy #: _________________________
Primary Care Physician:____________________________
Phone #: _________________________
Allergies to Insect/Medications/Foods: NO/YES If Yes, please explain: _______________________________
Do You Wear Glasses or Contacts NO/YES If Yes, please specify: __________________________________
MEDICAL HISTORY QUESTIONNAIRE
1. Please list any previous significant injuries your child has sustained: ______________________________
____________________________________________________________________________________
2. Have you had any prior surgery/surgeries? Please explain: _____________________________________
____________________________________________________________________________________
3. Have you had any illnesses or injuries in the past year that have kept you from participating in athletics or
school? If yes, please explain: ____________________________________________________________
____________________________________________________________________________________
4. Were you seen or treated by a doctor for the previous illness or injury? If yes, please name the physician
and the diagnosis: _____________________________________________________________________
____________________________________________________________________________________
5. Have you ever suffered from a concussion that was diagnosed by a physician or an Athletic Trainer? If
yes, how many times and when: __________________________________________________________
6. Have you ever suffered from a hit to the head where you have had a headache, nausea, dizziness, or
lightheaded? If yes, how many times and when: _____________________________________________
7. Have you ever been diagnosed with any of the following; if you answer yes, please explain:
a. Headache or Migraines: (NO/YES):____________________________________________
b. Learning Disability or Dyslexia: (NO/YES): ______________________________________
c. ADD/ADHD: (NO/YES): ____________________________________________________
d. Depression, Anxiety, or any other psychiatric Disorder: (NO/YES): ___________________
________________________________________________________________________
e. Seizure Disorder: (NO/YES): ________________________________________________
8. Have you been told by a doctor not to participate in a certain sport? If yes, please explain: ___________
__________________________________________________________________________________
9. Do you have asthma, diabetes, or heart related conditions that the Athletic Trainer should be aware of?
Please explain: ________________________________________________________________________
____________________________________________________________________________________
10. Do you have a medical condition that requires the use of medication? Please list all medications (asthma
inhalers, insulin, epi-pens, etc) and explain: _________________________________________________
____________________________________________________________________________________
11. Are you required to wear protective devices such as knee, ankle or shoulder braces as directed by a
physician? If yes, please explain: _________________________________________________________
12. Are there any other medical conditions the Athletic Trainer should be aware of: _____________________
____________________________________________________________________________________
I hereby authorize in advance any necessary medical treatment required for my son/daughter while he/she is participating in
Nauset Regional High School activities. This includes treatment by the certified athletic trainer on site, EMT’s, team
physician (Dr. Andrew Judelson) and school physician (Dr. Nancy Golden), and emergency medical staff at area hospitals.
I have read the student athlete handbook at Nauset Regional High School and will abide by its guidelines and maintain good
athletic citizenship while participating in athletics at Nauset Regional High School.
I herewith give permission for my son/daughter to participate in athletics and all trips and activities related to the athletic
program.
I also give permission for my child _________________________ to receive Tylenol (2 tablets, 650mg), Calcium carbonate
(Tums) and/or Ibuprofen (2 tablets, 400mg). If at all possible over the counter medication should be given out at home prior to
school and/or athletics.
NEW THIS YEAR MANDATED CONCUSSION COURSE INFORMATION:
I have been given all information regarding head injuries and trauma that can be sustained while participating in athletics at
Nauset Regional High School. It is understood that I will review the material given by the MIAA and Nauset Regional High
School and will use the CDC website to complete the sports concussion awareness course on line @ www.nfhslearn.com.
This is in accordance with the MIAA & the Commonwealth of Massachusetts Department of Public Health. All parents or
guardians are required to do so prior to the start of the athletic season. It is further understood that as parent(s) or
guardian(s) you acknowledge that you have successfully completed said course. Please print a copy of the completion
certificate for your records.
Notice of risk: Student athletes and the student’s parent or guardian need to be aware that sports activities involve risk of
injury. When an athlete practices, plays or participates in any sport, the activity can be dangerous. The student risks
serious, permanent injury, and possibly death. Instructions given by the coach/certified athletic trainer regarding playing
techniques, hitting techniques (where applicable), weight training, proper equipment usage and team rules must be followed.
X Student’s Signature: __________________________ __ Date: ________
X Parent’s/Guardian’s Signature: ____________________ Date: ________