Preparticipation Physical Evaluation CLEARANCE FORM

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1 Preparticipation Physical Evaluation CLEARANCE FORM Name Sex M F Age of birth Cleared for all sports without restriction Cleared for all sports without restriction with recommendations for further evaluation or treatment for Not cleared Pending further evaluation For any sports For certain sports Reason Recommendations I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined above. A copy of the physical exam is on record in my ofice and can be made available to the school at the request of the parents. If conditions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and parents/guardians). Name of physician/nurse practitioner (print/type) Address Phone Signature of physician/nurse practitioner Title EMERGENCY INFORMATION Allergies Other information 2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.

2 Medical Card for Athlete Interscholastic High School Athletics MCPS Form October 2010 MONTGOMERY COUNTY PUBLIC SCHOOLS Rockville, Maryland INSTRUCTIONS: This card should be kept on ile in the medical kit for each sport. It should accompany the athlete to the doctor or hospital when medical attention is required. Student Name: Birth : School Name: Student ID #: Home Address: Parent/Guardian Name: Home #: Work #: Cell #: Work #: Cell #: Parent/Guardian Name: Home #: If parent cannot be reached, person to be contacted in case of emergency Name: Home #: Relationship: Work #: Cell #: over

3 MEDICAL CARD FOR ATHLETE Family Physician: Physician #: Hospital Preference: of Last Tetanus Shot: Allergies: Medicine Administered on the Field: INSURANCE INFORMATION: Does your son/daughter have medical insurance? Yes No If Yes, Name of Insurance Company: RELEASE FOR TREATMENT: I hereby give permission to the attending physician or hospital to administer appropriate medical treatment in the event I cannot be reached. Signature Parent/Guardian: This card must be kept on ile in the medical kit for each sport and should be available at all practices and contests. It must accompany the athlete to the doctor or hospital when emergency medical attention is required.

4 MONTGOMERY COUNTY PUBLIC SCHOOLS (MCPS) STUDENT-PARENT ATHLETIC PARTICIPATION CONTRACT AND PARENT PERMISSION FORM Student: Student ID: School: Team: School Year: Parent and Student-Athlete: Review this contract carefully (front and back), complete information as requested, affix signatures, and return the completed contract/permission form to the school. Stipulations We have received and read the Student-Parent Athletic Participation Information. Based on this information, we understand and stipulate to the following. I/We: 1. Understand the eligibility regulations required for participation and affirm that all eligibility requirements have been satisfied, including age, residence, and academics. 2. Understand that participation of ineligible players shall result in individual and team sanctions, including forfeits for the team. 3. Affirm that the student will exert effort to maintain a high level of academic achievement. 4. Understand there is potential for serious, catastrophic, or life-threatening injury associated with participation in a sport. 5. Acknowledge receipt and review of safety and health information made available by the school system, including information regarding concussions, MRSA, hygiene, heat acclimatization, hydration, steroids, and sudden cardiac arrest. 6. Affirm that the student shall not participate in hazing at any time, of any nature. 7. Shall exhibit, as a participant or spectator, a high level of sportsmanship at contests. 8. Shall follow appropriate procedures in communicating concerns to coaches. 9. Affirm that the student will abide by all team and participation standards. 10. Shall utilize appropriate, positive use of technology, including social media and other electronic communications. 11. Affirm that the student shall not use steroids, illegal drugs, alcohol, and tobacco unless medically prescribed for a specific condition or illness. 12. Shall allow certified athletic trainers contracted by MCPS to administer emergency and first aid care to our child, as allowed by the Code of Maryland Regulations (COMAR), the National Athletic Trainers Association (NATA), the Maryland Board of Physicians, and MCPS policies and regulations. Residency Verification In order to be eligible, students must be legally enrolled at a high school designated by the school system based on their legal primary address. Please respond to the following residency questions: A. I reside at Street Address B. C. D. E. F. City This residence is within the boundaries of I reside at this residence with my parent(s) or legal guardian: My current address is the same as last year: I have only played at my current high school: I agree to notify the coach / school of any changes in residence: 3 MD Zip Code High School/Consortium yes no yes no yes no yes no

5 Permission to Participate I/We hereby authorize and consent to our child s participation in interscholastic athletics and sports. We understand that the sport in which our child will be participating is potentially dangerous, and that physical injuries may occur to our child requiring emergency medical care and treatment. I/We assume the risk of injury to our child that may occur in an athletic activity. In consideration of the acceptance of our child by MCPS in its athletic program, and the benefits derived by our child from participation, I/we agree to release and hold harmless the Board of Education of Montgomery County, its members, the Superintendent of Schools, the principal, all coaches, and any and all other of their agents, servants, and/or employees, as well as entities that provide training to MCPS coaches and/or athletes as part of the school system s athletic program, and agree to indemnify each of them from any claims, costs, suits, actions, judgment, and expenses arising from our child s participation in interscholastic athletics. I/We hereby give our consent and authorize the Board of Education of Montgomery County and its agents, servants, and/or employees to consent on our behalf and on behalf of our child, to administer emergency medical care and treatment in the event we are unable to be notified by reasonable attempts of the need for such emergency medical care and treatment. Each year, MCPS makes available a student accident insurance policy at a nominal premium. This insurance is secondary to the family's own insurance. Because accidents will inevitably occur despite our best efforts to maintain a high level of safety in all student activities, this insurance coverage is recommended unless the family deems that other insurance coverage (in force) will meet the needs of the student. The student accident insurance policy is available at the beginning and throughout the school year. The coverage may be obtained from the insurance carrier. Forms are available at the school. I,, and I, (parent s name) (student s name) have carefully reviewed the Student- Parent Athletic Participation Information and the Student/Parent Athletic Participation Contract and Parent Permission Form. I/We understand the conditions for participation in the MCPS interscholastic athletic program, and we understand there are inherent risks associated with participation. I/We agree as follows: My son/daughter has my/our permission to participate in (name of sport) at High School. I/We understand and conform to all of the statements in the Stipulations portion of the Contract. I/We I have responded truthfully and accurately to the questions in the Residency portion of the Contract. Please affix signatures below. Signature of Parent or Legal Guardian Signature of Student Signature of Parent or Legal Guardian *In the event that both parents retain legal guardianship of the student, the signatures of both parents are required. 4

6 Revised July 2014 Consent Form ImPACT Baseline Concussion Testing We have read the information provided by Montgomery County Public Schools (MCPS) and information outlined in the Health and Safety section of the Athletics page of the MCPS website regarding baseline concussion testing and ImPACT (Immediate Post-concussion Assessment and Cognitive Testing). We understand the contents and agree to complete baseline concussion testing in order to participate in interscholastic athletics. A baseline concussion test is good for two years a student-athlete would need to retake the test every two years. We also give our consent to have a retest administered in the event of a concussion. We know that it is our responsibility to request a retest (or multiple retests) from the school. The school will not automatically administer a retest in the event of a concussion or suspected concussion. We understand that a student-athlete must be cleared by a medical professional in order to return to play following a concussion or suspected concussion. Results of the ImPACT test or retests do not have to be utilized in order to return to participation. But in many instances ImPACT tests can provide valuable information that can assist medical professionals in making decisions on when a student may safely resume participation. We understand that there is no cost to parents for retests. Furthermore, we give permission for the school-assigned vendor to release the ImPACT results to our child s primary care physician, neurologist, or other testing physician, as indicated below. I/We also understand that general information about the test data may be provided to our child s guidance counselor and teachers, for the purpose of providing temporary academic modifications, if necessary, following a concussion. Student Name: Sport Signature of Student-Athlete Signature of Parent/Guardian

7 For official use only: Name of Athlete Sport/season Received Parent/Student Athlete Acknowledgement Statement Parent/Guardian I acknowledge that I have read and understand the following: Sudden Cardiac Arrest (SCA) Information Sheet Concussion Awareness Information Sheet PRINT NAME PARENT/GUARDIAN SIGNATURE Student Athlete I acknowledge that I have read and understand the following: Sudden Cardiac Arrest (SCA) Information Sheet Concussion Awareness Information Sheet PRINT NAME STUDENT ATHLETE SIGNATURE

8 *** DETACH THIS PAGE ONLY AND HAND TO THE COACH ONLY *** PARENT AND STUDENT TEAM STANDARDS The following standards are in effect for all extracurricular participants and parents. Additional standards may be established by the coach/sponsor. 1. Maintain academic standing and scholastic eligibility as established by Montgomery County Public Schools. It is the student s responsibility to be familiar with the regulations as outlined in the Students Rights and Responsibilities Handbook and adhere to these standards. 2. Display proper behavior that will add to the good name of Thomas S. Wootton High School. 3. Maintain good school and community relationships. 4. Comply with all school rules and policies. 5. Display good sportsmanship at all times as well as adheres to the MCPS Sportsmanship Statement and Expectations. Major or consistent violations of school rules and policy by extracurricular participants will result in removal from the team or activity. Infractions may be brought before a Wootton Coaches Review Board for consideration. Major violations of school rules and policies by spectators will result in removal from that event and possibly future Wootton athletic events. I HAVE READ, UNDERSTOOD, AND AGREED TO THE ABOVE GUIDELINES FOR PARTICIPATION IN THOMAS S. WOOTTON HIGH SCHOOL ATHLETICS. ATHLETE SIGNATURE: DATE: ATHLETE S PRINTED NAME: PARENT SIGNATURE: PARENT S PRINTED NAME: DATE:

9 EXTRACURRICULAR ACTIVITY FEE REMITTANCE FORM DETACH form and send payment to address below. Do not pay the school directly. For your convenience,you may pay online at Extracurricular Activity Fee Remittance Form Return to MCPS, ECA Office, 45 West Gude Drive, Suite 3201, Rockville, MD Student Name: Street: City, State, Zip: Student ID: School Name: Grade: Parent/Guardian Name (please print) MAKE CHECKS PAYABLE TO MCPS. DO NOT FOLD OR STAPLE FORM. $ Gross family income is more than $35,000 $15 - Gross family income is less than $35,000 (You must enclose proof of income.) MCPS Form # June 2015

10 MEMBERSHIP FORM Show Your Support! Parent Name(s) Address Phone Number Fall Sport Name SPORTS Winter Sport Spring Sport Name Name Student Athlete Grade Family Membership Dues: ($50.00*) $ *Family membership is for all sports for the entire school year! Additional Optional Donation Appreciated: I. II. Patriot Gold $ (Includes 4x8 Paver at Stadium Entrance) Patriot Silver: $ $50.00 $ III. Patriot Bronze: $25.00 $ IV. Other Amount $ Total: $ Check # I don t have a child on a team, but I want to support the athletic department and teams as a Boosters member. My business is interested in corporate sponsorship or buying a sign. I would like to volunteer to with Booster Club activities. Please contact me! Suggestions or Comments: Please mail this form and your check, payable to the Wootton Booster Club, to: Wootton High School Booster Club Attn: Membership 2100 Wootton Parkway Rockville, MD OR JOIN ONLINE AT: THANK YOU & GO PATRIOTS!

11 Patriots Track Schedule Conflict Form Please review the schedule for the upcoming Indoor Track season. If you have any obligations or commitments already scheduled that conflict with any of the team functions, including practices, record them on the form below. Obligations and commitments include but aren t limited to: family vacations, doctor s appointments, SATs, academic meetings, etc. Athletes will be excused without penalty on the dates listed on this form but are expected to be at all other team functions. Parents and athletes should do everything in their power to avoid scheduling anything that conflicts with team functions after this form has been submitted. This form must be submitted by Friday, November 11 th if the athlete wishes to be excused on the dates listed. of Conflict Time of Conflict Reason for Conflict Athletes Name: Athletes Signature: Parent Signature:

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