Date                                                                               Sport                                                                         

 

 

SPORTS CANDIDATES' QUESTIONNAIRE

(To be completed by Parent/Guardian)

 

DEAR PARENT/GUARDIAN:  Your son/daughter has indicated a desire to participate in athletic activities sponsored by the Bay Shore Schools. To be eligible to participate in school sponsored athletic activities, your child must pass a screening provided by the school physician.  In lieu of this, you may submit proof of a physical examination from your family physician on the proper school form.  Please answer the following questions in reference to your child:

 

 

STUDENT                                                                  GRADE                   BIRTHDATE                                    

 

PARENT/GUARDIAN NAME                                                                    TELEPHONE     #                              

 

ADDRESS                                                                                                                                                        

 

                                                                                                                                    (Please Circle One)

 

Was your child injured or ill this summer requiring the services of a physician and/or               Yes               No

hospitalization?

If yes, please specify and attach a note from your physician indicating that the student is         

able to participate in extracurricular activities.

 

Is he/she under a physician’s care now?  (Ex: seizures, asthma, diabetes)                                Yes               No       

If yes, please explain.                                                                                                                                         

 

Does he/she take medication now?                                                                                      Yes               No

If yes, please list name of medication and the reason for the prescription.

 

Do you know any reason why your child should not participate in sports?                               Yes               No

 

Does your child have a history of passing out during or after exercise, chest discomfort           Yes               No       

during exercise, skipped beats during exercise, family history of sudden death and/or

personal history of any previous cardiovascular findings?

 

Has your child ever had a head injury or concussion?                                                            Yes               No

If yes, how many previous concussions and when?

                                                                                                                                    (PLEASE CHECK ONE)

I give permission for the school nurse to notify my child’s coach of any above listed conditions.  YES   NO

 

PLEASE NOTE:  Students may not participate in contact sports if there is absence or limited vision in one eye, severe myopia, significant hearing loss or has any medical problem for which contact would be contraindicated.  If you have

any questions, please call (631) 968-1186, prompt #5.

 

 

                                                                                                                                                                                                                           

Signature of Parent/Guardian                                                                         Date                                                                                                                                                                                           NURSE/

FOR OFFICE USE ONLY:    DR. EXAM_________  PPQ_________  U/A_________  DATE________

 

 

(over)

BAY SHORE UNION FREE SCHOOL DISTRICT

Department of Health, Physical Education and Athletics

 

 

SPORT_____________________________________________

 

 

Please complete the sections below and the Sports Candidates Questionnaire on reverse side.  This form must be completed and returned before participation in the program.

 

TO BE COMPLETED BY PARENT/GUARDIAN:

I hereby give consent for my son/daughter                                                                                                                        to compete in

(sport)                                                                                     which my private or the school physician has given medical clearance

for the current school year.  I give permission for my child’s health care provider to be contacted by the school nurse to

clarify any medical information for sports clearance.  I shall be held financially responsible for the loss of any issued equipment. 

I give my permission for my child to go on any field trips that the team makes under the supervision of the coach.

 

I hereby acknowledge an awareness that participation in sports involves a risk of injury, and that these injuries may occur in

some instances as the result of unavoidable accidents.  I accept these risks in giving consent to participation in the above

noted sport.

 

I understand that the district’s student accident insurance policy is a supplemental coverage program which excludes certain

items and is limited to a plan maximum of $25,000.  I understand that if I do not have insurance or Medicaid coverage for my

child, the district’s student accident coverage will become primary, subject to its exclusions and limits.

 

                                                                                                                                                                                                                               

Signature of parent/guardian                                                                             Phone Number                    

 

                                                                                                                                                                                                                               

Name of family physician                                                                                   Phone Number         

 

Name and telephone number of person to contact in case of emergency                                                                                             

 

TO BE SIGNED BY STUDENT ATHLETE:

I am aware that participating in any sport can be a dangerous activity involving many risks of injury.  I understand that the dangers and risks of participating in sports may include death, neck and spinal injuries, complete or partial paralysis, brain damage, injury to the muscular-skeletal  system, as  well  as injury to other parts of my body.  I understand  that  the dangers of  playing sports

may result not only  in injury but the impairment of my future abilities to live a full and productive life. Because of the dangers of

participating in sports, I recognize the importance of following coaches’ instructions regarding conditioning, playing techniques training and other team rules, etc., and agree to obey such instructions.

 

I agree to abide by all rules regarding the use of alcohol and drugs.  I understand that alcohol and drug addiction is a disease

and  even  though it  may be treatable,  it has serious  physical and emotional effects -- effects that would hurt  me, my family,

my team and my school.  Given the serious dangers of alcohol and drug use, I accept and pledge to follow all rules and laws established by my school, team, and community regarding the use of alcohol and drugs.

 

                                                                                                                                                                                                                               

Signature of Student Athlete                                                             Street Address & Town

 

TO BE SIGNED BY PARENT/GUARDIAN AND STUDENT ATHLETE:

We have read and understand the Bay Shore Union Free School District Attendance Policy, Eligibility Policy,

Code of Conduct and Spectator Code of Conduct.

 

                                                                                                                                                                                                                                   Signature of Parent/Guardian                                                                                             Signature of Student Athlete

 

TO BE SIGNED BY PARENT/GUARDIAN:

I give the school nurse permission to contact my child’s healthcare provider for clarification on medical information

regarding sports clearance.

 

                                                                                                                                                                                                                               

Signature of Parent/Guardian                                                                                                                 Date

 

/ljb (revised 7/2008)