Nauset Regional High School
Athletic Department
PO Box 1887
North Eastham, MA 02651
For Office Use Only
Date to Athletic Office: ______Physical Date: ______
Cleared to Play: ______Filed: ______
PHYSICAL DATE MUST BE AFTER: July 23rd, 2009
Please Sign All Paperwork at Each X
RETURN BY: June 25th, 2010
PARTICIPATION
To participate in the interscholastic athletic program, students must pass a sports physical examination with in thirteen months of the beginning of the season, have permission of their parents or guardian for participating in each sport, maintain academic and citizenship standings according to the Massachusetts Interscholastic Athletic Association. Athletes are required to be present at all practices/athletic contests during school vacation, ie: winter, February, and April vacations.
PLEASE CIRCLE ONE SPORT:
BOYS: FOOTBALL SOCCER CROSS COUNTRY GOLF
GIRLS: FIELD HOCKEY SOCCER CROSS COUNTRY VOLLEYBALL
CO-ED: CHEERLEADING
EMERGENCY CONTACT INFORMATION
This form is to be used by the athletic trainer or EMT on site, in the event of an emergency when you cannot be reached. Please complete, sign, and return this form to the school prior to the first practice of the athletic season.
Student’s Name: ______Birthdate: ______SS#: ______
Year of Graduation: ______Parent’s Name:______
Address: ______City: ______Zip Code: ______
Phone #: ______Work #: ______Cell #: ______
Parent E-Mail Address: ______
Student Email: ______
In Case of an Emergency Contact: ______Phone #:______
(Other than Parent or Guardian)
Primary Care Physician:______Phone #:______
Insurance Group: ______Policy #: ______
Allergies to Insect/Medications/Foods: NO/YES If Yes, please explain: ______
Do You Wear Glasses or Contacts NO/YES: ______
MEDICAL HISTORY QUESTIONNAIRE
1. Please list any previous significant injuries your child has sustained:______
______
2. Have you had any prior surgery/surgeries? Please explain: ______
______
3. Have you been sick or had any injuries in the past year? If yes, please explain: ______
4. Were you seen or treated by a doctor for the previous illness or injury? If yes, please name the physician and the diagnosis: ______
5. Have you ever suffered from a concussion that was diagnosed by a physician or an Athletic Trainer? If yes, how many and when: ______
6. Have you been told by a doctor not to participate in a certain sport? If yes, please explain: ______
7. Do you have asthma, diabetes, or heart related conditions that the Athletic Trainer should be aware of? Please explain:______
______
8. Do you have a medical condition that requires the use of medication? Please list all medications (asthma inhalers, insulin, epi-pens, etc) and explain: ______
______
9. Are you required to wear protective devices such as knee, ankle or shoulder braces as directed by a physician? If yes, please explain: ______
______
10. Are there any other medical conditions the Athletic Trainer should be aware of: ______
______
I hereby authorize in advance any necessary medical treatment required for my son/daughter white he/she is participating in Nauset Regional High School activities.
I herewith give permission for my son/daughter to participate in athletics and all trips and activities related to the athletic program.
I also give permission for my child ______to receiveTylenol (2 tablets, 650mg), Calcium carbonate (Tums) and/or Ibuprofen (2 tablets, 400mg). If at all possible over the counter medication should be given out at home prior to school and/or athletics.
Notice of risk: Student athletes and the student’s parent or guardian need to be aware that sports activities involve risk of injury. When an athlete practices, plays or participates in any sport, the activity can be dangerous. The student risks serious and permanent injury which may affect his or her well-being. Instructions given by the coach regarding playing techniques, training and team rules must be followed.
X Student’s Signature: ______Date: ______
X Parent’s/Guardian’s Signature: ______Date: ______
PLEASE READ CAREFULLY AND SIGN BELOW
Sport: ______Year of Graduation: ______
HAZING
Hazing is considered a crime in Massachusetts. The Massachusetts General Law is defined in CH. 269, s. 17 as: “Any conduct or method of initiation into any student organization, whether on private or public property, which willfully or recklessly endangers the physical or mental health of any student or other person. Such conduct shall include whipping, branding, forced calisthenics, exposure to weather, forced consumption of food, liquor, beverage, drug or other substance, or any other brutal treatment of forced physical activity which is likely to adversely affect the physical health or safety of any student or other person, or which subjects such student or other person to extreme mental stress, including extended deprivation of sleep or rest or extended isolation.” Consent to such treatment does NOT make it legal.
CHEMICAL HEALTH POLICY
From the start of the first fall practice, August 23rd, 2010 until June 30th, 2011, a student shall not, regardless of the quantity, use, consume, possess, buy, sell, or give away beverages containing alcohol, any tobacco product, marijuana, steroids, or any controlled substance. It is not a violation for a student to be in possession of legally defined drug specifically prescribed for the student’s own use by his or her doctor. This includes all athletes, not just those that are in season.
MINIMUM PENALTIES:
First Violation: when the Principal confirms, following an opportunity for the students to be heard, that a violation occurred, the students shall lose eligibility for 25% of all regular schedule interscholastic contests (the penalty can span athletic seasons and school years). However, it is recommended that the student be allowed to remain at practice for the purpose of rehabilitation.
Second and Subsequent Violations: when the Principal confirms, following an opportunity for the students to be heard, that a violation occurred, the students shall lose eligibility for 60% of all regular schedule interscholastic contests (the penalty can span athletic seasons and school years).
If after the second or subsequent violation, the student of his or her volition becomes a participant in an approved chemical dependency program or treatment program, the student may be certified for reinstatement in regular scheduled interscholastic contests after a minimum of 40% of events. Penalties shall be cumulative for each school year and may extend into the next season or next school year. For the out of season athlete, the penalty will commence at the start or the next athletic season.
I have read and understood the law on HAZING and CHEMICAL HEALTH POLICY above. I understand and agree to all the rules and policies stated therein. I also acknowledge that I have been properly advised of all my rights as well as my responsibilities representing Nauset Regional High School as a member of an athletic team.
X Student’s Name: ______Date: ______
X Student’s Signature: ______Date: ______
X Parent’s/Guardians Signature: ______Date: ______
PLEASE FILL OUT AND RETURN TO:
KEITH ARNOLD OR MICHELE PAVLU
NAUSET REGIONAL HIGH SCHOOL ATHLETICS
PO BOX 1887
NORTH EASTHAM, MA 02651
EMERGENCY CARD