Athletic_Dept._Forms_packet by niusheng11


									                                          Green Local School District
                               THIS MEDICAL FORM IS GOOD FOR ONE SCHOOL YEAR

Student Name____________________________                    Today’ Date ________________________
Address        ___________________________                  Grade Level at Participation_____________
               ___________________________                  Home Phone_________________________
City/State/Zip ___________________________                  Cell Phone___________________________

We hereby consent for the above named student to engage in an athletic activity. As such, we hereby release the Green
Board of Education, it’s officers, members, employees and agents, in both their official and individual capacities from any
and all liability for any injury that might be sustained by our child while traveling to and from the sports
contests/practices or while participating in such sports.

__________________________________________                     ______________________________________
Signature – Parent/Guardian                                    Signature – Parent/Guardian

                             CONSENT - EMERGENCY MEDICAL TREATMENT
If our child requires emergency treatment as a result of an illness or injury, we hereby grant consent for the
emergency treatment. In addition, please notify us at the following:

__________________________________________                     ______________________________________
Signature – Parent/Guardian  (date)                            Signature – Parent/Guardian (date)

Mother’s name _________________________________________________________
Phone #’s (h)____________________(c)_________________(w)_________________

Father’s name __________________________________________________________
Phone #’s (h)____________________(c)_________________(w)_________________

Other Contact’s name ____________________________________________________
Phone #’s (h)____________________(c)_________________(w)_________________

In the event reasonable attempts to contact me have been unsuccessful, I (we) hereby give consent for:
    (1) The administration of any treatment deemed necessary by the below named doctor, or, in the event the
        designated preferred practitioner is not available, by another licensed physician or dentist and
    (2) The transfer of the child to any hospital reasonably accessible. This authorization does not cover
        major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in
        the necessity for such surgery, are obtained prior to the performance of such surgery.

Doctor: _____________________________________Phone___________________

Facts concerning the child’s medical history including allergies, medications, etc. to which a physician should be

                             NON-CONSENT - EMERGENCY MEDICAL TREATMENT
            (Complete only if you are NOT giving consent for emergency medical treatment as outlines above)
We DO NOT give consent for emergency treatment as a result of illness or injury to the above named student. In
the event of an illness or injury requiring emergency treatment, we wish school authorities to take the following

__________________________________________                     ______________________________________
Signature – Parent/Guardian  (date)                            Signature – Parent/Guardian (date)
                               ATHLETIC DEPARTMENT
STUDENT’S NAME___________________________________ School Year _______________

                                      ACKNOWLEDGEMENT OF RISK
The Green Schools will attempt to protect your child from serious injury and to properly care for those injuries that
may occur. All human activities, including sports, have the potential for injury causing occurrences. Sports
injuries can range from minor, such as cuts, bumps and bruises to serious such as sprains and fractures, possibly
requiring surgery to catastrophic such as eye injuries, head, neck and back injuries with possible paralysis, even to,
although rare, death.

We acknowledge that the risk of injuries described above and other risks, are present in the sports offered in the
Green Schools. We grant our child permission to assume these risks while participating in these sports.

___________________________________________ ____________________________________________
Student Signature                     Date    Parent/Guardian Signature            Date

We have received/read the Athletic Handbook for Student Athletes and Parents.

___________________________________________ ____________________________________________
Student Signature                     Date    Parent/Guardian Signature            Date

We understand that Green Athletics is a school sponsored activity and that the Green Local School District Athletic
Code of Conduct applies. We realize that a Code of Conduct violation may result in a loss of privileges and/or
result in appropriate school discipline.

_________________________________________                 ___________________________________________
Student Signature                    Date                  Parent/Guardian Signature             Date

                                                           Parent/Guardian Signature            Date
                          TRANSPORTATION CONSENT
We hereby give consent for the above named student to travel to and from any athletic contest and/or practice by:
(initial all that apply) __________________ ______________________ ________________________
                             Bus                     School Van                    Private Vehicle
And we are aware that it is our responsibility to provide necessary to all practices.

Parent/Guardian Signature            Date

We grant permission for the photographs or videotapes to be used in media presentations that are made available to
other educational institutions or through a cable television station or network. We further grant permission for
photographs to be used in the print media. We understand that our child’s image, name, work product, school
and/or grade may be revealed in the presentation(s) but that no other information about our child or his/her work
will be revealed without prior consent.

Parent/Guardian Signature            Date
                                      Green Local Schools
                                  Sports Participation Insurance
Each sports participant should be covered by accident insurance. Green Local Schools are not liable for,
nor, responsible for payment of treatment in connection with injuries received in any sport. This policy
has always been in effect in Green Local Schools.

Parents are encouraged to purchase the school insurance to supplement their other coverage. It does,
however, contain limitations and it not intended to be the primary coverage.

All athletes are covered by the Ohio High School Athletic Association Lifetime Catastrophe Accident
Insurance which pays, after deductible of $25,000. Benefits for covered losses in excess of other valid
and collectible insurance to an aggregate limit of $3,000,000. Copies of the policy are available from the
office of the O.H. S.A.A.

                                         Green Local Schools
                                     Sports Participation Insurance

The parent/guardian is responsible for coverage up to $25,000.00 by employment, home accident
insurance or the school master policy, which contains a rider specifying that:
     For a premium of $146.00 (triple option), a student will be covered up to $100,000.00 for injuries
       sustained during school, football practices, games and during all other school-sponsored classes
       and activities;
     For a premium of $130.00 (triple option), a student will be covered up to $25,000. During football
       practices, games, and during school-sponsored classes and activities and coverage during summer
       months, weekends, all vacation periods, 24 hours a day, anywhere in the USA – coverage year
       round until the start of the next football season, (up to $100,000. other than football). The
       premium excludes dental coverage.

                                          Green Local Schools
                                     Sports Participation Insurance
                                     All Sports (excluding football)

There are two recommended options for accident insurance for athletes. They are as follows:
   1. Employment or home accident insurance which applies to the athlete.
   2. Student accident insurance which is offered through the school for a minimal cost per year for the
       “School Time Coverage Plan”, or you may also purchase a “Full Time Coverage Plan with
       Increased Dental Benefits” for an additional cost.

STUDENT’S NAME ____________________________ SPORT _________________

I am the parent or legal guardian of the above named student. We do, hereby, assume all
responsibility for our son/daughter’s participation. And also assume full responsibility for payment of
medical and/or hospital expenses. We are fully aware that Green Local Schools are not liable for
payment of any medical and/or hospital expenses for injuries that might occur in any sport.

FATHER’S OCCUPATION _______________________ EMPLOYER _____________

MOTHER’S OCCUPATION _______________________ EMPLOYER _____________

Do you have insurance? ___________ Type: Employment          School (circle one)

With Whom? _______ Does this include full hospitalization? ______ Major Medical? _______

I wish to carry school insurance on my son/daughter _______ - if yes, forms are available in the
Athletic Office.

Have you completed an Emergency Medical Form? ____________ (Yes or No)

                               *** SIGNATURE OF PARENTS***

_______________________________________                 ____________________________________
Mother or Guardian          Date                        Father or Guardian          Date

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