DEPARTMENT OF ATHLETICS

COLUMBIA GRAMMAR AND PREPARATORY SCHOOL

2019 Fall Season

Emergency Information Form

Student's Name (First)required

Student's Name (Last)required

Agerequired

Grade (Fall of 2019)required

D.O.Brequired (mm/dd/yyyy)

Home Telephonerequired

Home Addressrequired

Which team are you participating/trying out for this season?required

Parent/Guardian 1required

Emailrequired

Telephone numbers:

Home

Cell

Work

Parent/Guardian 2

Telephone numbers:

Home

Cell

Work

EMERGENCY CONTACTS (if parent(s)/guardian cannot be reached)

(1)required

Relationship to studentrequired

Phonerequired

(2)required

Relationship to studentrequired

Phonerequired

More Information:

Physicianrequired

Addressrequired

Phonerequired

Hospital Affiliationrequired

Dentistrequired

Addressrequired

Phonerequired

Consent to Treat: I hereby authorize all representatives of the Columbia Grammar and Preparatory School to obtain on behalf of my son/daughter first aid, emergency medical care, or, if necessary, admission to the closest health care facility should such care become necessary for the treatment of any medical emergency or injuries my son/daughter may sustain while participating in school activities. I also consent to the administration of emergency medical treatment in the event I am unable, subsequent to such medical emergency or injury, to give timely consent as otherwise would be necessary. All qualified medical personnel are hereby notified that this authorization is currently in effect and such personnel are directed to act upon such authorization without delay. I understand that reasonable efforts will be made to contact parents, my son/daughter’s physician, and/or the emergency contacts given by me on this form. I also give my permission to the school to release medical information as appropriate to school staff/faculty with respect to school activities

Parent/Guardian Initialrequired

I acknowledge by checking this box that I (the guardian) has read the above information*

*Students in Grades 7-12 who have been prescribed an inhaler or epi-pen are required to carry such medications with them at all times during school activities.

Prior to the start of each season (fall, winter, and spring), New York State Education law requires that each student-athlete submit a Health History Update unless he/she has received a full medical examination within 30 days of the start of the season. This update covers only the time period since the student-athlete’s most recent annual physical exam, a record of which must be on file in the nurse’s office.

INFORMATION TO BE PROVIDED BY PARENT OR GUARDIAN (medical provider input is NOT required)

Note: A “YES” response to any of the questions below does not automatically disqualify your son/daughter from an activity. However, it may require further review by the school nurse, physician, or athletic trainer before he/she may participate.

Afterthe date of the medical exam specified above, has the student-athlete experienced any of the following:

Does your son/daughter have any additional medical concerns/needs that we should be aware of?*

Yes No

Please explain

Any injuries requiring medical attention?*

Yes No

Please explain

Head injury or concussion?*

Yes No

Please explain

Any illness lasting more than 5 days?*

Yes No

Please explain

Is he/she taking medicine or under a physician's care at this time?*

Yes No

Please explain

Change in vision regarding glasses or contact lenses?*

Yes No

Please explain

Headaches?*

Yes No

Please explain

Asthma with an inhaler prescribed?*

Yes No

Please explain

Any allergies?*

Yes No

Specific allergiesrequired

An allergy action plan has been submitted?*

Yes No

Has an epi-pen been prescribed?*

Yes No

Please explain

Would you like your child's epi-pen, any additional medication, and allergy protocol to be kept in the coach's first aid kit? (If you mark yes, please contact akhan@cgps.org to make arrangements)*

Yes No

Any treatment in a hospital or emergency room?*

Yes No

Please explain

Any chronic diseases?*

Yes No

Please explain

Change in nutritional habits?*

Yes No

Please explain

Change in activity/exercise program?*

Yes No

Please explain

Specifically during or after exercise,

has the student experienced any one or more of the following symptoms?

As a result of the above checked symptom, was a medical evaluation done?

Yes No

I, the undersigned, clearly understand that these questions are asked to determine if a student can safely participate on the team listed at the top of this form. The answers are correct as of this date and my son/daughter has permission to participate.

Health information may be shared on a “need to know” basis with appropriate members of the educational team for use in meeting the student's health and educational needs. In the event of serious illness or injury, the student may receive first aid or be transported by EMS to an emergency department for evaluation and treatment, including X-rays and other required tests. Every attempt will be made to contact parents in advance of treatment; when necessary, however, the alternate contact or designated school employee may act in the interest of the student on behalf of the parent. The most current emergency contact information has been provided to the athletics department on a separate form.

Parent/Guardian Initialrequired

I acknowledge by checking this box that I (the guardian) has read the above information*

Athletic Travel and Dismissal Consent

This form indicates your directive for your son/daughter’s dismissal from athletic events during the 2019–2020 school year. Any deviation from this directive, including permission for your son/daughter to leave with another parent, must be made in writing.

All Columbia Prep teams travel to and from games and practices via chartered bus, or on foot. Students are not allowed to drive to and from any athletic events. Athletes in grades 7-12 will return to Columbia Prep by the same mode of transportation unless given permission for alternate means, as indicated below.

I GIVE PERMISSION FOR MY SON/DAUGHTER TO ...

My son/daughter may leave a game or practice at any time during the school year with any other parent on the team.*

Yes No

If possible, my son/daughter may exit the team bus at a cross street on the east or west side of Manhattan (decided upon by the coach) when returning to school from a practice or game.*

Yes No

My son/daughter may leave games or practices directly (alone or with friends) and travel home unaccompanied by an adult. *

Yes No

Student-Athlete Contract

PARENT CONSENT:required

This signed form gives my consent for my son/daughter

to participate on an interscholastic athletic team sponsored by Columbia Grammar and Preparatory School. While the coaching staff and other responsible school officials will do everything within reason to protect my child against injury, I understand that injuries may occur and on a very rare occasion may be serious and disabling. I am also aware that athletic participation will involve travel and that all travel involves some risk of serious injury. I/We have read and agree to abide by the policies and expectations for athletic participation stated here and in the Athletic Handbook. Failure to abide by the expectations may result in removal from an athletic team.

1) Commitment is a fundamental requirement for athletic participation and is directly related to the success of a team and the development of the athlete. Attendance at all games and practices is expected and required. It is important to note that games and practices may be rescheduled during the course of a season. Therefore, an athlete’s schedule must remain flexible during the sport season as to meet the commitment made to his/her team. Absence from school should be the only reason an athlete misses a practice or game. If there is an unavoidable circumstance in which an athlete must miss a practice or a game, the athlete must directly notify the coach or Director of Athletics in advance.

2) As a member of a Columbia Prep team, athletes representing the school are expected to uphold the highest standard of sportsmanship and ethical behavior.

3) Team issued equipment and uniforms are the responsibility of the athlete and must be returned promptly and in good condition at the end of the season. Athletes will be billed for any lost or damaged school issued equipment or clothing.

4) Athletes must have an annual physical on file in the nurse’s office to participate in athletics. We agree to notify the school if there is any change to an athlete’s medical or physical condition that develops or is discovered after the physical is performed. An athlete is required to notify his/her coach or the athletic trainer if he/she sustains any injury while participating in practice or a game. The trainer can assess the extent of an injury and recommend the appropriate course of action. An athlete who has been removed from athletic participation by a doctor must have a doctor’s clearance note to return to play.

5) If an athlete has a question or concern he/she is strongly encouraged to speak to their coach directly. If further action is required, parents can contact coaches or the Director of Athletics.

Guardian Initialrequired

I acknowledge by checking this box that I (the guardian) has read the above information*

Athlete Initialrequired

I acknowledge by checking this box that I (the athlete) has read the above information*

Athletic form checklist

- Annual Physical Form is on file in the school nurse’s office. Physical is only valid for one calendar year. Student-athletes may not participate in athletics without a current physical.

Date of most recent physicalrequired (mm/dd/yyyy)

I have read and understand each of the following documents-

Concussion Management Statement(click here).
Concussion Management Protocol For Return To Play(click here).
NYSPHSAA Concussion Student and Parent Information Sheet(click here).

Parent/Guardian Signaturerequired

Date required (mm/dd/yyyy)

I understand that checking this box constitutes a legal signature*

Student-Athlete Signaturerequired

Date required (mm/dd/yyyy)

I understand that checking this box constitutes a legal signature*

Please send a confirmation email to the address below*: