MIDDLE SCHOOL OF THE KENNEBUNKS ATHLETIC CARD 2016-2017 Athlete Name:___________________________________________________ Home Address:_____________________________________________ Father’s Name:__________________________________________________ Mother’s Name:_____________________________________________ Father’s Work Telephone:__________________________________________ Mother’s Work Telephone:_____________________________________ Father’s Home Telephone:_________________________________________ Mother’s Home Telephone:____________________________________ Father’s Cell Telephone:___________________________________________ Mother’s Cell Telephone:______________________________________ EMERGENCY CONTACT IN CASE PARENTS NOT AVAILABLE:_________________________________________________ Phone:_______________ HEALTH/ACCIDENT INSURANCE THIS IS REQUIRED BEFORE PARTICIPATING IN ANY MSK SPORT Insurance Company:_________________________________________________ Policy Number:_____________________________________ Name on Policy:_______________________________________________________________________________________________________________

MANAGEMENT OF CONCUSSION AND OTHER HEAD INJURIES The athlete and his/her parent(s)/guardian(s) have received, read and understand the policy regarding the Management of Concussion and Other Head Injuries as provided by RUS #21 and the KHS Athletic Department. Athlete Signature:_______________________________ Parent/Guardian Signature:______________________________________ Date:______________

PARENTAL ACKNOWLEDGEMENT AND PERMISSION The answers to all questions on this card are correct. I understand that the student named on this card is covered by a family accident and insurance plan. Students may not participate without this coverage. If you do not have such coverage you may purchase insurance through the school. I understand that any misrepresentation of any of the information contained herein will result in the student being denied the opportunity to participate. I hereby give my consent to the participation of the student/athlete listed above in the RSU 21 athletic program. Parents and guardians should be aware that such activity involves the potential for injury which is inherent in all sports. I/we acknowledge that even the best coaching, use of the most advanced protective equipment and strict observation of rules, injuries are still a possibility. On rare occasions these injuries can be so severe as to result in total disability, paralysis, or even death. I/we acknowledge that I/we have read and understand this warning. I shall assume all responsibility and expense for any injury received in practice or participation. I give my permission for my son/daughter to be diagnosed and treated by a licensed physician should such service be necessary.

Parent Signature:_________________________________________________________________ Date:____________________________

STUDENT NAME:_____________________________ Male Female Age______ DOB

/ /

GR 6 7

8

Personal Doctor / Doctor Phone Number:_____________________________/________________

HEALTH HISTORY

TO BE COMPLETED BY PARENT -EXPLAIN YES

Have you ever been hospitalized? Have you ever had surgery? Are you presently taking medication? Do you have any allergies? Have you ever had a head injury? Have you ever been knocked out/unconscious? Have you ever had a seizure? Have you ever had a stinger, burner? Have you ever had trouble breathing during exercise? Have you ever sprained a joint? Have you ever dislocated a joint?

ANY “YES” ANSWERS AT THE BOTTOM

NO

YES

NO

Have you ever passed out during exercise? Have you ever been dizzy during exercise? Have you ever had chest pain during exercise? Have you ever had high blood pressure? Have you ever been told you have a heart murmur? Have you ever had a racing of your heart? Has your heart ever skipped beats? Has anyone in your family had a heart problem under age 50? Have you ever broken a bone? Do you have any medical problems such as asthma, epilepsy, diabetes, arthritis, mononucleosis? Do you use any special equipment such as pads, braces, neck rolls, mouth guard, eye guard?

When was your last Tetanus (TD) booster? DATE: (Month/Year) _______/______ Do you have…..glasses_______ contact lenses________ orthodontia work (braces, etc.)__________ Please explain any YES answers from the box above: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ PHYSICAL EXAMINATION THIS MUST BE DONE BY A PHYSICIAN, NURSE PRACTITIONER OR PHYSICIAN ASSISTANT The above athlete has been examined by me and is medically cleared to participate in competitive interscholastic athletics. Signature:_____________________________________________ MD/DO/NP/PA Date of Examination:____________________ Date Cleared to Participate_______________