Sports Participation Packet | Palisades Park High School Athletic Forms

STUDENT & EMERGENCY MEDICAL PROFILE INFORMATION

Your son/daughter has requested the privilege of taking part in our athletic program. Before he/she may take part, it is necessary for us to have your consent by completing the forms included in this packet.

Have you participated in a previous sport during the 2018-2019 school year and/or have a valid physical on file with the school nurse?*

Yes
No

School (for the 2018-2019 school year)*

Winter Sport*

Student-Athlete Name*

First Last

Gender*

Student Email*

Grade (for 2018-2019 school year)*

Student Age*

Date of Birth*

Home Phone*

STUDENT ADDRESS

Student Address*

Street Address City State ZIP Code

Parent/Guardian/Emergency Contact Information

Parent-Guardian #1 Name*

First Last

Parent-Guardian #1 Email*

Home Phone*

Work Phone*

Cell Phone*

Parent-Guardian #2 Name

First Last

Parent #2 Email

Work Phone

Cell Phone

Emergency Contact (other than guardian)*

First Last

Relationship*

Home Phone*

Work Phone*

Cell Phone*

Physician/Medical Information

Physician Name

First Last

Phone

Physician Address

Street Address City State ZIP Code

Dentist Name

First Last

Phone

Dentist Address

Street Address City State ZIP Code

Known Allergies- medicines, insects, et...*

Write 'none' if you do not have any allergies.

Does your child wear glasses?*

Yes
No

Does your child wear contacts?*

Yes
No

Medications taken if any:*

Medical Conditions-Previous Injuries*

List any operations or illnesses your child has had since his last physical.

Preferred Hospital:*

Date of Last Tetnus:*

PARENTAL CONSENT

The team physician, trainer and coach may apply first aid treatment until the family doctor can be contacted.*

Yes
No

We give our consent for team physician, trainer and coaches to use their own judgement in securing medical aid and ambulance service in case the parents cannot be reached.*

Yes
No

Parental Consent*

In order to participate in Interscholastic Sports, a student must have this forn completed prior to the first day of practice. The physical examination section must be completed by the school physician or your family doctor. Each candidate for a place on a school athletic team shall be given a medical examination by the medical inspector or designated team doctor no more than 90 days prior to the first practice session, or in lieu thereof, the medical inspector may accept the report of such an examination by a physician licensed to practice medicine. Each candidate must undergo one medical examination in each school year. A medical re-evaluation shall be given to every athlete who has been previously injured in any sport and intends to participate in the following seasonal sport activity. I hereby give my consent for my child to participate in the athletic program sponsored by Palisades Park High School as listed below. I am aware of the inherent risk of injury in all sports. I/We acknowledge that even with the best of coaching, use of the most advanced protective equipment and strict observance rules, injuries are still a possibility. I realize the risk may be severe, including the risk of fractures, total disability, brain injuries, paralysis even death. I/We acknowledge that I/We have read and understand this warning. I have read all the information herein and grant permission to my son/daughter to participate in Inter Scholastic Athletics.

Athletic Packet- High School- 2018-2019

Step 1 of 7

STUDENT & EMERGENCY MEDICAL PROFILE INFORMATION

STUDENT ADDRESS

Parent/Guardian/Emergency Contact Information

Physician/Medical Information

PARENTAL CONSENT

NJSIAA Concussion Policy Acknowledgement Form

NJSIAA Steroid Testing Policy Consent To Random Testing

Sudden Cardiac Death in Young Athletes

Opioid Use and Misuse Fact Sheet

HEALTH HISTORY UPDATE

PREPARTICIPATION PHYSICAL EVALUATION

Declaration