ATHLETIC CONTRACT Please initial each statement below to acknowledge your agreement to this contract. Then, sign the form at the bottom and return to the Athletic Director to be eligible for participation. As a Maureen Joy Charter School Student-Athlete I will strive to give my best to the team in every practice and every game. I will be on time for all practices and games. I will not miss a practice or game because of another outside sport or extra-curricular activity unless approved by the coach or athletic director. This experience is an opportunity to learn not only (sport), but also teamwork with all its inherent responsibilities. There will be times when I will follow someone s lead and there will be times when I must assume that lead I always have a contribution to make to my team. I will take my coaches directions and comments as constructive suggestions, which make me a better athlete and my team a successful unit. Practice is where I learn the concepts of the game. How I apply those concepts in mind and body in practice will carry over into the game situation. I will always play hard, but always will be a fair sport whether we are winning or losing the game, realizing that everyone on my team and my opponent s team is playing for fun and the competitive experience. I have read the athletic handbook and agree to follow the policies and procedures as stated. Player Signature: Date: Parent Signature: Date: PLEASE RETURN THIS FORM TO THE ATHLETIC DIRECTOR
Maureen Joy Charter School Athletic Permission Form Name of Athlete Grade: Important: The following information must be completed and signed by the appropriate parent or guardian and turned in to the Athletic Director before participation in student athletic activities will be allowed. If the following information is not complete, this form will be returned to you. Insurance: Parent/Guardian : Address: City: State: Zip Code: Home Phone: Work Phone: Cell/Emergency Phone Number: All students participating in student athletic activities at Maureen Joy Charter School must have their own medical coverage. Students will not be allowed to participate in student athletic activities unless the following information is submitted and the form is signed by the parent or the guardian of the student. Insurance Company: Policy Holder: Policy and Group Number: Address or phone number of insurance company: Signature of Parent or Guardian Date: Wavier of Liability We, the undersigned, hereby certify that I (we) am (are) the parent or legal guardian of the student. I hereby give permission to the staff/volunteer coaches of Maureen Joy Charter School to seek during the period of school athletic activities, appropriate medical attention and for the student to receive medical attention and treatment to be covered under the student s insurance policy detailed on this form. I/We the undersigned, for ourselves, our heirs, our executor and administrator, waiver, release, and forever discharge Maureen Joy Charter School and its staff, officers, agents, employees, representatives, successors and assigns from any and all liability claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, personal injury or property damage that may be sustained or occur during participation in student athletic activities or while in transit to and from games/practices. Signature of Parent or Guardian
Maureen Joy Charter School Sports Preparticipation Examination Form Patient s Name: Age: This is a screening examination for participation in sports. This does not substitute for a comprehensive examination with your child s regular physician where important preventive health information can be covered. Athlete s Directions: Please review all questions with your parent or legal custodian and answer them to the best of your knowledge. Parent s Directions: Please assure that all questions are answered to the best of your knowledge. If you do not understand or don t know the answer to a question please ask your doctor. Not disclosing accurate information may put your child at risk during sports activity. Physician s Directions: We recommend carefully reviewing these questions and clarifying any positive or Don t Know answers. Explain Yes answers below Yes No Don t 1. Does the athlete have any chronic medical illnesses [diabetes, asthma (exercise asthma), kidney problems, etc.]? List: Know 2. Is the athlete presently taking any medications or pills? 3. Does the athlete have any allergies (medicine, bees or other stinging insects, latex)? 4. Does the athlete have the sickle cell trait? 5. Has the athlete ever had a head injury, been knocked out, or had a concussion? 6. Has the athlete ever had a heat injury (heat stroke) or severe muscle cramps with activities? 7. Has the athlete ever passed out or nearly passed out DURING exercise, emotion or startle? 8. Has the athlete ever fainted or passed out AFTER exercise? 9. Has the athlete had extreme fatigue (been really tired) with exercise (different from other children)? 10. Has the athlete ever had trouble breathing during exercise, or a cough with exercise? 11. Has the athlete ever been diagnosed with exercise-induced asthma? 12. Has a doctor ever told the athlete that they have high blood pressure? 13. Has a doctor ever told the athlete that they have a heart infection? 14. Has a doctor ever ordered an EKG or other test for the athlete s heart, or has the athlete ever been told they have a murmur? 15. Has the athlete ever had discomfort, pain, or pressure in his chest during or after exercise or complained of their heart racing or skipping beats? 16. Has the athlete ever had a seizure or been diagnosed with an unexplained seizure problem? 17. Has the athlete ever had a stinger, burner or pinched nerve? 18. Has the athlete ever had any problems with their eyes or vision? 19. Has the athlete ever sprained/strained, dislocated, fractured, broken or had repeated swelling or other injury of any bones or joints? qhead qshoulder qthigh qneck qelbow qknee qchest qhip qforearm qshin/calf qback qwrist qankle qhand qfoot 20. Has the athlete ever had an eating disorder, or do you have any concerns about your eating habits or weight? 21. Has the athlete ever been hospitalized or had surgery? 22. Has the athlete had a medical problem or injury since their last evaluation? FAMILY HISTORY 23. Has any family member had a sudden, unexpected death before age 50 (including from sudden infant death syndrome [SIDS], car accident, drowning)? 24. Has any family member had unexplained heart attacks, fainting or seizures? 25. Does the athlete have a father, mother or brother with sickle cell disease?
Elaborate on any positive (yes) answers: By signing below I agree that I have reviewed and answered each question above. Every question is answered completely and is correct to the best of my knowledge. Furthermore, I give permission for my child to participate in sports. Signature of parent/legal custodian: Date: Phone #: Signature of Athlete: Date:
Physical Examination (Must be Completed by a Licensed Physician, Nurse Practitioner or Physician s Assistant) Athlete s Name Age Date of Birth Height Weight BP ( % ile) / ( % ile) Pulse Vision R 20/ L 20/ Corrected: Y N PULSES HEART LUNGS SKIN NECK/BACK SHOULDER KNEE ANKLE/FOOT Other Orthopedic Problems HEENT ABDOMINAL GENITALIA (MALES) HERNIA (MALES) These are required elements for all examinations NORMAL ABNORMAL ABNORMAL FINDINGS Optional Examination Elements Should be done if history indicates Clearance**: q A. Cleared q B. Cleared after completing evaluation/rehabilitation for : q C. Not cleared for: q Collision q Contact q Non-contact Strenuous Moderately strenuous Non-strenuous Due to: Additional Recommendations/Rehab Instructions: Name of Physician/Extender: Signature of Physician/Extender: MD DO PA NP (Signature and circle of designated degree required) Date of exam: Address: Phone: (** The following are considered disqualifying until appropriate medical and parental releases are obtained: post-operative clearance, acute infections, obvious growth retardation, diabetes, jaundice, severe visual or auditory impairment, pulmonary insufficiency, organic heart disease or hypertension, enlarged liver or spleen, a chronic musculoskeletal condition that limits ability for safe exercise/sport (i.e. Klippel-Feil anomaly, Sprengel s deformity), history of convulsions or concussions, absence of/ or one kidney, eye, testicle or ovary, etc.)
Maureen Joy Charter School Authorization to Treat a Minor Form I (We), the undersigned parent, parents or legal guardian of Minor s Name authorize any hospital or clinic or licensed physician to treat my/our child, charge with any x-ray examination, anesthetic, medical or surgical diagnosis rendered under the general or special supervision of any member of the medical staff of the hospital/clinic or office of a physician who are licensed to practice in the State of North Carolina. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power to render care when effort shall be made to contact the undersigned prior to rendering treatment to the patient, but that treatment will not be withheld if the undersigned cannot be reached. Signature of Coach/Witness Signature of Parent/Legal Guardian Date Phone Date Phone List any restrictions to your authorization to treat: Date minor received last tetanus/diphtheria booster: List any allergies to drug(s) or food(s) minor may have: Any special medication(s) or other pertinent information on minor: This consent shall remain effective until the end of the minor s participation in: or until: Expiration date I give my consent for my child s coach to administer the following over-the-counter medications: Ibuprophen Acetaminophen Neosporin Benadryl (for allergic reaction only), Topical Hydrocortisone (for allergic reaction only) Other, please list below: