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ATHLETE EMERGENCY INFORMATION CARD 2008/2009 NAME:_____________________________ SPORT: _______________ DATE OF LAST PHYSICAL:____________________________ GRADE:

ADDRESS:_________________________________________ BIRTH DATE: _______________

PHONE NUMBER (S):___________________________________________________________________________ EMERGENCY CONTACT NAME: _______________________ EMERGENCY CONTACT PHONE #:________________________________ INSURANCE CO: ______________________ ADDRESS:________________________________ PHONE #: ___________________________ DO I NEED PRE-AUTHORIZATION? ____________ POLICY #: _____________________________ID #: _____________________________ PRIMARY CARE PHYSICIAN: ___________________________ PHONE #: _____________________ ARE YOU HOME SCHOOLED? YES NO ARE YOU A TRASFER STUDENT? YES NO IF YES, WHAT SCHOOL:___________________________________ History Questions: 1. Do you have any Allergies? YES NO Comments:______________________________________________ 2. Are you taking any Medications? YES NO Comments:______________________________________________ 3. Have you ever been told you have a Heart Murmur? YES NO Comments:______________________________________________ 4. Have you ever had a Concussion seen by a doctor? YES NO Comments:______________________________________________ 5. Do you have Asthma? YES NO Comments:______________________________________________ 6. Do you wear Glasses or Contacts? YES NO Comments:______________________________________________ 7. Do you have any medical history that I need to know? YES NO Comments:______________________________________________ Please include any surgeries, illnesses or injuries that are pertinent to the sports season

Hopkinton Public Schools Athletics Parental Consent, Release from Liability and Indemnity Agreement We the undersigned father and mother or guardian(s) of ___________________________________ A minor, do hereby consent to his/her participation in voluntary athletic programs and do forever RELEASE, acquit, discharge, and covenant to hold harmless the Town of Hopkinton, State of Massachusetts, and its successors, departments, officers, employees, servants and agents, of and from any and all actions, causes of actions, claims, demands, damages, costs, loss of services, expenses and compensation on account of, or in any way growing out of, directly or indirectly, all known and unknown personal injuries or property damages which we/I may now or hereafter have as the parent(s) or guardians(s) of said minor, also all claims or right of action for damages which said minor has or hereafter may acquire, either before or after he/she has reached his/her majority resulting or to result from his/her participation in the Hopkinton Public Schools Athletic Department’s athletic programs; FURTHERMORE, we/I hereby agree to protect the Town of Hopkinton and its successors, departments, officers, employees, servants, and agents, against any claims for damages, compensation or otherwise on the part of said minor growing out of or resulting from injury to said minor in connection with his/her participation in the Hopkinton Public Schools Athletic Department’s voluntary athletic programs, and to INDEMNIFY, reimburse or make good to the Town of Hopkinton or its successors, departments, officers, employees, servants and agents any loss or damages or costs, including attorney’s fees, the Town or its representatives may have to pay if any litigation arises from said minor’s intentional, grossly negligent, or reckless acts or omissions while participating in said sports programs. Parent/Guardian Signature:____________________________

Date:____________________________

Athlete’s Signature:___________________________________

Date:____________________________

CONSENT TO TREAT I understand that my child may be injured while participating in athletics at Hopkinton High School. I authorize the school to obtain through the athletic trainer, nurse, coach +/or available physician any emergency care that may become necessary while participating in or traveling under the Hopkinton high School Athletic program. PARENT SIGNATURE ___________________________________________________________

DATE:__________________


PARENT CONSENT/HANDBOOK I hereby certify that I have read the Hopkinton Middle/High School Handbook for Athletes and give permission for my Child to play the sports indicated on the other side of this form. PARENT SIGNATURE ___________________________________________________________

DATE:__________________

STUDENT HANDBOOK I hereby certify that I have read the Hopkinton Middle/High School Handbook for Athletes. ATHLETE SIGNATURE __________________________________________________________

DATE:__________________

STUDENTS/COACHES ATHLETIC CODE As a citizen, I know that the use of alcohol or drugs is unlawful. As a student, I realize that the use of alcohol, drugs, or tobacco is unhealthy. As an athlete, I recognize that the use of alcohol, drugs (including steroids) and tobacco impairs my mental and physical ability and thereby, my performance. Recognizing this, I understand and accept that the use of alcohol, tobacco or other drugs during school time or at schoolsponsored activities will subject me to the same disciplinary action as any other student. I further understand and accept that additional disciplinary action may be taken by the Athletic Department, and that such action could include being declared ineligible for varsity participation for up to one full academic year. Further, because of my status as a student-athlete and because other participants generally depend on the quality of my performance as an athlete, I agree to abide by any additional agreements between the team and the coach that seek to regulate behavior or activities that might affect training and conditioning. These agreements would be developed by team members, captains, and coaches; cover behavior or activities away from school and school-sponsored functions; and will be monitored and enforced by team members and captains. I realize and accept that failure to abide by these agreements might also result in disciplinary action, including exclusion from team participation. I hereby certify that I have read and understand the STUDENTS/COACHES ATHLETIC CODE as well as the Hopkinton Middle School/High School Handbook for Athletes. _______________________________________________ Student’s Signature

______________________________ Date

_______________________________________________ Parent’s Signature

______________________________ Date

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