BADGER HIGH SCHOOL ATHLETICS
2015-2016
BADGER HIGH SCHOOL
2015-2016
MUST BE COMPLETED AND SIGNED BY THE ATHLETE’S PARENT/GUARDIAN (PLEASE PRINT)
1.
CONSENT FOR ATHLETIC TRAINING SERVICES & EMERGENCY MEDICAL TREATMENT
Student’s Name: _______________________________________________________________________________________________________ Address: _______________________________________________________________ City: ___________________________ Zip: __________ Grade: 9
10
11
12
Sex: M
F
Date of Birth: _________________
Age: _______________
Parent/Guardian Name: _____________________________________________________________
Home Phone: ____________________
E-Mail: __________________________________________________________________
Father’s Name:
_________________________________________________________
Place of Employment: ______________________________________________________
Mother’s Name:
_________________________________________________________
Place of Employment: ______________________________________________________
Cell: ___________________________ Work Phone: ____________________ Cell: ___________________________ Work Phone: ____________________
In case of emergency and absence of parent/guardian; please list two people you recommend we call:
Name: _____________________________________________ Relationship: _______________ Phone: _________________________
Name: _____________________________________________ Relationship: _______________ Phone: _________________________
List any known allergies: _________________________________________________________________________________________________ List any medications the student is taking: ____________________________________________________________________________________ List any physical disabilities: _______________________________________________________________________________________________ Additional Comments: ____________________________________________________________________________________________________ Name of Medical Insurance Company of Plan: _______________________________________________ Health Maintenance Organization (HMO)? [ ] Yes
[ ] No
Policy #: ________________________
If Yes, what is your primary facility: __________________________________
Family Physician: ______________________________________________________________________
Phone #: _______________________
Family Dentist: ________________________________________________________________________
Phone #: _______________________
Consent & Authorization…I hereby authorize the employed or contracted staff of the Badger High School Athletic Department (i.e., coaches, athletic trainers, team physician, and/or other assigned medical personnel) to provide athletic training services to my son/daughter/ward and to secure and medical assistance on behalf of my son/daughter/ward. I further authorize these individuals to discuss my son/daughter/ward’s medical condition with other health care personnel, which the Department deems appropriate. To the fullest extent permitted by law, I do indemnify and hold harmless the Department, entities, and other persons who act in reliance upon this authorization. Parent/Guardian Signature: _______________________________________________________Date: __________________________
2. PARENTAL PERMISSION
1. 2.
I hereby give permission for the above-named student to practice & compete & represent the school in WIAA &/or Badger High School approved sports. I also attest to the fact that the named student on Page 1 has had no injury or illness serious enough to warrant a medical evaluation prior to participating this school year. 3. Pursuant to the requirements of the Health Insurance Portability & Accountability Act of 1996 & the regulations promulgated thereunder (collectively known as “HIPAA”), I authorize health care providers of the named student on Page 1, including emergency medical personnel & other similarly trained professionals that may be attending an interscholastic event/practice, to disclose/exchange essential medical information regarding the injury & treatment of this student to appropriate school district personnel such as but not limited to: Principal, Athletic Director, Athletic Trainer, Team Physician, Team Coach, Athletic Director Adm. Assistant &/or other professional health care providers, for purposes of treatment, emergency care & injury record-keeping. 4. It is recommended that information regarding your child’s allergies & prescribed medication be made available. PARENT/GUARDIAN: If there is any question that this student may not be qualified for athletic competition without, at least, a partial reevaluation, contact your medical advisor before signing. Parent/Guardian Signature: ______________________________________________________ Date: __________________________
3. BADGER HIGH SCHOOL CO-CURRICULAR CODE OF CONDUCT AGREEMENT
FOUND ONLINE AT LAKEGENEVASCHOOLS.COM / BADGER / STUDENTS / ATHLETICS / SPORTS INFORMATION TO BE SIGNED BY STUDENT: As a prospective participant in a Badger High School Co-Curricular activity that involves contests/performances/events, I agree to follow the expectations of the Co-Curricular Activity Code of Conduct (outlined in my Student Handbook). Furthermore, I am aware of the penalties, which will be imposed if I elect to violate any of the provisions of this Co-Curricular Code of Conduct. Student Signature: _____________________________________________________________Date: ___________________________ TO BE SIGNED BY PARENT/GUARDIAN: My son/daughter will be participating in a Co-Curricular activity at Badger High School. I agree to support the provisions in the Co-Curricular Code of Conduct and expect him/her to abide by the policy provisions. Parent/Guardian Signature: _____________________________________________________Date: __________________________
4. WISCONSIN INTERSCHOLASTIC ATHLETIC ASSOCIATION HIGH SCHOOL ATHLETIC ELIGIBILITY INFORMATION BULLETIN FOUND ONLINE AT LAKEGENEVASCHOOLS.COM / BADGER / STUDENTS / ATHLETICS / SPORTS INFORMATION
TO BE SIGNED BY PARENT/GUARDIAN AND STUDENT: I certify that I have read, understand, and agree to abide by all of the information contained in this bulletin. I further certify that if I have not understood any information contained in this document, I have sought and received an explanation of the information prior to signing this statement. Student Signature: _____________________________________________________________Date: ___________________________ Parent/Guardian Signature: ______________________________________________________ Date: __________________________
5.
STATEMENT ACKNOWLEDGING RECEIPT OF EDUCATION & RESPONSIBILITY TO REPORT SIGNS OR SYMPTOMS OF CONCUSSION TO BE INCLUDED AS PART OF THE “PARTICIPANT & PARENTAL DISCLOSURE & CONSENT DOCUMENT” FOUND ONLINE AT LAKEGENEVASCHOOLS.COM / BADGER / STUDENTS / ATHLETICS / SPORTS INFORMATION
I hereby acknowledge having received education about the signs, symptoms, & risks of sport related concussion. I also acknowledge my responsibility to report to my coaches, parent(s)/guardian(s) any signs or symptoms of a concussion. I certify that I have read, understand, & agree to abide by all of the information contained in this sheet. I further certify that if I have not understood any information contained in this document, I have sought & received an explanation of the information prior to signing this statement. Student Signature: _____________________________________________________________Date: ___________________________ I, the parent/guardian of the student athlete named above, hereby acknowledge having received education about the signs, symptoms, & risks of sport related concussion. I certify that I have read, understand, & agree to abide by all of the information contained in this sheet. I further certify that if I have not understood any information contained in this document, I have sought & received an explanation of the information prior to signing this statement. Parent/Guardian Signature: ______________________________________________________ Date: __________________________
SECTIONS 1-5 MUST BE COMPLETED IN FULL & SUBMITTED TO THE BADGER ATHLETIC OFFICE PRIOR TO THE STUDENT BEING DECLARED ELIGIBLE TO PRACTICE & COMPETE
BADGER HIGH SCHOOL
2015-2016
MUST BE COMPLETED AND SIGNED BY THE ATHLETE’S PARENT/GUARDIAN (PLEASE PRINT)
1.
CONSENT FOR ATHLETIC TRAINING SERVICES & EMERGENCY MEDICAL TREATMENT
Student’s Name: _______________________________________________________________________________________________________ Address: _______________________________________________________________ City: ___________________________ Zip: __________ Grade: 9
10
11
12
Sex: M
F
Date of Birth: _________________
Age: _______________
Parent/Guardian Name: _____________________________________________________________
Home Phone: ____________________
E-Mail: __________________________________________________________________
Father’s Name:
_________________________________________________________
Place of Employment: ______________________________________________________
Mother’s Name:
_________________________________________________________
Place of Employment: ______________________________________________________
Cell: ___________________________ Work Phone: ____________________ Cell: ___________________________ Work Phone: ____________________
In case of emergency and absence of parent/guardian; please list two people you recommend we call:
Name: _____________________________________________ Relationship: _______________ Phone: _________________________
Name: _____________________________________________ Relationship: _______________ Phone: _________________________
List any known allergies: _________________________________________________________________________________________________ List any medications the student is taking: ____________________________________________________________________________________ List any physical disabilities: _______________________________________________________________________________________________ Additional Comments: ____________________________________________________________________________________________________ Name of Medical Insurance Company of Plan: _______________________________________________ Health Maintenance Organization (HMO)? [ ] Yes
[ ] No
Policy #: ________________________
If Yes, what is your primary facility: __________________________________
Family Physician: ______________________________________________________________________
Phone #: _______________________
Family Dentist: ________________________________________________________________________
Phone #: _______________________
Consent & Authorization…I hereby authorize the employed or contracted staff of the Badger High School Athletic Department (i.e., coaches, athletic trainers, team physician, and/or other assigned medical personnel) to provide athletic training services to my son/daughter/ward and to secure and medical assistance on behalf of my son/daughter/ward. I further authorize these individuals to discuss my son/daughter/ward’s medical condition with other health care personnel, which the Department deems appropriate. To the fullest extent permitted by law, I do indemnify and hold harmless the Department, entities, and other persons who act in reliance upon this authorization. Parent/Guardian Signature: _______________________________________________________Date: __________________________
2. PARENTAL PERMISSION
1. 2.
I hereby give permission for the above-named student to practice & compete & represent the school in WIAA &/or Badger High School approved sports. I also attest to the fact that the named student on Page 1 has had no injury or illness serious enough to warrant a medical evaluation prior to participating this school year. 3. Pursuant to the requirements of the Health Insurance Portability & Accountability Act of 1996 & the regulations promulgated thereunder (collectively known as “HIPAA”), I authorize health care providers of the named student on Page 1, including emergency medical personnel & other similarly trained professionals that may be attending an interscholastic event/practice, to disclose/exchange essential medical information regarding the injury & treatment of this student to appropriate school district personnel such as but not limited to: Principal, Athletic Director, Athletic Trainer, Team Physician, Team Coach, Athletic Director Adm. Assistant &/or other professional health care providers, for purposes of treatment, emergency care & injury record-keeping. 4. It is recommended that information regarding your child’s allergies & prescribed medication be made available. PARENT/GUARDIAN: If there is any question that this student may not be qualified for athletic competition without, at least, a partial reevaluation, contact your medical advisor before signing. Parent/Guardian Signature: ______________________________________________________ Date: __________________________
3. BADGER HIGH SCHOOL CO-CURRICULAR CODE OF CONDUCT AGREEMENT
FOUND ONLINE AT LAKEGENEVASCHOOLS.COM / BADGER / STUDENTS / ATHLETICS / SPORTS INFORMATION TO BE SIGNED BY STUDENT: As a prospective participant in a Badger High School Co-Curricular activity that involves contests/performances/events, I agree to follow the expectations of the Co-Curricular Activity Code of Conduct (outlined in my Student Handbook). Furthermore, I am aware of the penalties, which will be imposed if I elect to violate any of the provisions of this Co-Curricular Code of Conduct. Student Signature: _____________________________________________________________Date: ___________________________ TO BE SIGNED BY PARENT/GUARDIAN: My son/daughter will be participating in a Co-Curricular activity at Badger High School. I agree to support the provisions in the Co-Curricular Code of Conduct and expect him/her to abide by the policy provisions. Parent/Guardian Signature: _____________________________________________________Date: __________________________
4. WISCONSIN INTERSCHOLASTIC ATHLETIC ASSOCIATION HIGH SCHOOL ATHLETIC ELIGIBILITY INFORMATION BULLETIN FOUND ONLINE AT LAKEGENEVASCHOOLS.COM / BADGER / STUDENTS / ATHLETICS / SPORTS INFORMATION
TO BE SIGNED BY PARENT/GUARDIAN AND STUDENT: I certify that I have read, understand, and agree to abide by all of the information contained in this bulletin. I further certify that if I have not understood any information contained in this document, I have sought and received an explanation of the information prior to signing this statement. Student Signature: _____________________________________________________________Date: ___________________________ Parent/Guardian Signature: ______________________________________________________ Date: __________________________
5.
STATEMENT ACKNOWLEDGING RECEIPT OF EDUCATION & RESPONSIBILITY TO REPORT SIGNS OR SYMPTOMS OF CONCUSSION TO BE INCLUDED AS PART OF THE “PARTICIPANT & PARENTAL DISCLOSURE & CONSENT DOCUMENT” FOUND ONLINE AT LAKEGENEVASCHOOLS.COM / BADGER / STUDENTS / ATHLETICS / SPORTS INFORMATION
I hereby acknowledge having received education about the signs, symptoms, & risks of sport related concussion. I also acknowledge my responsibility to report to my coaches, parent(s)/guardian(s) any signs or symptoms of a concussion. I certify that I have read, understand, & agree to abide by all of the information contained in this sheet. I further certify that if I have not understood any information contained in this document, I have sought & received an explanation of the information prior to signing this statement. Student Signature: _____________________________________________________________Date: ___________________________ I, the parent/guardian of the student athlete named above, hereby acknowledge having received education about the signs, symptoms, & risks of sport related concussion. I certify that I have read, understand, & agree to abide by all of the information contained in this sheet. I further certify that if I have not understood any information contained in this document, I have sought & received an explanation of the information prior to signing this statement. Parent/Guardian Signature: ______________________________________________________ Date: __________________________
SECTIONS 1-5 MUST BE COMPLETED IN FULL & SUBMITTED TO THE BADGER ATHLETIC OFFICE PRIOR TO THE STUDENT BEING DECLARED ELIGIBLE TO PRACTICE & COMPETE
