Mountain ViewHigh SchoolIQ

Activity Insurance Questionnaire and Consent Form

(to be completed yearly for each grade)sports: ______

PERSONAL HISTORY

Last Name______First______MI_____

Home Phone______Birth date______Gender M F Graduation year______Address______City______Zip______

Parent/Guardian Name______Day Phone______

Relation______Evening Phone______

Parent/Guardian Name______Day Phone______

Relation______Evening Phone______

In case of an Emergency (when parents cannot be contacted)notify:Name______Relation______Phone______

INSURANCE INFORMATION

Is your athlete covered by a family health insurance policy? _____ Yes ______No

Primary Insurance Company______Insurance Subscriber______

Whose Name is policy under? ______Policy #______Group #______

Do you wish to purchase school health insurance? ______Yes ______No *MVHS doesnotautomatically provide coverage*

If YES, a premium will be required prior to participation in any IHSAA athletic activity. More information

can be obtained from the main office at (208) 855-4050.

MEDICAL INFORMATION

Last Physical______Last Tetanus______Allergies______

Health Problems______Current Medications______

Family Doctor______Phone Number______

Since the athlete’s last physical examination, have they:

Yes No Yes No

1) Had Surgery ______6) Had a Concussion ______

2) Been Hospitalized ______7) Been Unconscious ______

3) Been under a physicians care ______8) Had an Allergic Reaction ______

4) Had a Serious Illness ______9) Developed any Health problems ______

5) Had an injury requiring Physicians care ______

Please explain any YES answers and give date (use back if needed) __________

CONSENT FORM_

I hereby consent to the above named student-athlete participating in the interscholastic athletic program at MountainView High School. This consent includes travel to and from athletic contests and practice sessions.

I hereby give consent to the sports medicine department and/or coach to apply first aid treatment for an injury or injuries sustained during practice or games in interscholastic athletics sanctioned by Mountain View High School, until the parents/guardians can be contacted.

I hereby consent that in case the parents/guardians can’t be reached, the sports medicine department and/or coach may secure emergency medical services, if needed, as a result of an injury during participation in sanctioned practices/games scheduled by Mountain View High School.

Signature of Parent/Guardian______Date______

My participation in interscholastic athletics at Mountain View High School is entirely voluntary on my part and with the understanding that I have not violated any of the eligibility rules and regulation of the IHSAA and Mountain ViewHigh School.

Signature of Athlete______Date______

**ONLY FILL SECTION BELOW IF WAIVING ALL INSURANCE AND TAKING FULL RESOSPONSIBLILTY FOR ATHLETE**

I ______, understand and accept any and all medical expenses that may be incurred due to possible injury(ies)

(Parent/ guardian)

Sustained while participating in/a school-sanctioned activity(ies). The following waiver will cover the ______school year. My child will participate in the following sports during the above school year. (Please list each sport in the spaces provided below.)

  1. ______2. ______3. ______

This includes all practices, travel and game situation during the entire year (from August 1st until July 31st of the following year). I also understand that some type of insurance (including school insurance) has been recommended/offered for my child and I have chosen not to purchase any type of insurance for my child at this time.

______Date: ______Date: ______

Student athlete signature Parent/Guardian signature

______Date: ______Date: ______

Athletic Trainer LAT, ATCLuke Wolf (Athletic Director)