Walker Valley Athletic Training

PARENT/GUARDIAN CONSENT FORM

Athlete’s Name: __________________________________Date of Birth: ____________

Parent/Guardian Name:_____________________________ Phone #: ________________

I hereby give my consent for the above named student-athlete to participate in interscholastic athletics at Walker Valley High School during the 2004-2005 school year. I give my permission for said student to travel on all athletic trips scheduled for his or her team. I understand that, occasionally, a coach may assign my child to ride to an athletic event with a selected adult driver in a privately owned vehicle. In granting this permission I assume full responsibility for any and all damages to person or property caused by my child.

I agree that if it is determine that my child needs medical or dental treatment while participating in athletics, I will be responsible for any such treatment determine to be necessary by a physician, dentist, athletic trainer, or emergency medical personnel. I give my permission and consent to the Athletic Trainer to care for and provide appropriate medical treatment for my son/daughter in the event of injury. I also grant my permission and consent to the Athletic Trainer to dispense non-prescription over-the-counter medications such as Tylenol, Ibuprofen, Motrin, Pepto Bismol, and other like medications to my son/daughter when appropriate or per written and/or oral standing orders from WVHS affiliated team of physicians or other qualified physicians.

I UNDERSTAND THAT BY PARTICIPATING IN INTERSCHOLASTIC ATHLETICS, MY SON/DAUGHTER IS EXPOSING HIM/HERSELF TO THE RISK OF SERIOUS INJURY, INCLUDING PARALYSIS OR DEATH.

I also understand that my son/daughter is expected to adhere firmly to all established policies of his/her coach, the Walker Valley Athletic Department, the Bradley County School District, and the TSSAA. I affirm that my child legitimately resides in the Walker Valley High School attendance or had legal school district permission to attend Walker Valley High School.

Parent/Guardian Signature: ______________________________ Date: ____________

Student Signature: ______________________________________

Tri State Orthopedics

2700 Westside Drive * Suite 103 * Cleveland, TN * 37312

Phone: (423) 614-0097 * FAX: (423) 614-5680

I. EMERGENCY TREATMENT

To All Parents:

Since the malpractice question has come to the forefront, many hospitals and doctors will not treat a child without parent’s consent (unless a matter of life or death). It is requested that you complete the information below so that if your child requires a visit to the hospital while under the supervision of the school, this will allow the hospital to treat the injury.

EMERGENCY INFORMATION

Name: ______________________________ Sport: ___________________________ Sex: M _____ F _____

Grade: __________ Age: __________ Date of Birth: _____/_____/_____

Parent’s Name: ___________________________________________________________________________

Father’s SS#: ________________________________ Mother’s SS#: ________________________________

Work Address: ___________________________________________________________________________

Phone Number: ____________________________

Home Address: ___________________________________________________________________________

Phone Number: ____________________________

Another Person to Contact: __________________________________________________________________

Relationship: ___________________________ Phone Number: _________________________

Insurance Name: __________________________________________________________________________

Policy and Group Numbers: ______________________________________________________

ALLERGIES: ____________________________________________________________________________

Consent Statement: Authorizing Treatment

Parent’s Signature: ________________________________________________________________________

Student’s Signature (if over age 18): __________________________________________________________

II. PARENT’S CONSENT

I herby give my consent for _________________________________________________ to represent
(Name of Student)
______________________________________ in the sport of _______________________________.
(Name of School)

Date: ___________________________ Signature: ____________________________________

MED-03

TMA/TSSAA PREPARTICIPATION MEDICAL EVALUATION FORM

Personal History


Name	Sex	Age	DOB

Grade	Sport(s)

School

Personal Physician	Address		Telephone

Have you every had a preparticipation physical before? ___ Yes ___ No If yes, when/where ______________

Please explain “Yes” answers below.

Yes

No

Have you ever been hospitalized?

Have you ever had surgery?

Are you presently taking any medications or pills?

Do you have allergies (medicine, bees or other stinging insects?

Have you every passed out during exercise?

Have you ever been dizzy during or after exercise?

Have you ever had chest pain during exercise?

Do you tire more quickly than your friends during exercise?

Have you ever had high blood pressure?

Have you ever been told that you have a heart murmur?

Has anyone in your family died of heart problems or a sudden death before the age of 50?

Do you have any skin problems (itching, rashes, acne)?

Have you ever had a head injury?

Have you ever been knocked unconscious?

Have you ever had a seizure?

Have you ever had a stinger, burner or pinched nerve?

Have you ever had heat or muscle cramps?

Have you ever been dizzy or passed out in the heat?

Do you have trouble breathing or do you cough during or after activities?

Do you use any special equipment (pads, braces, neck role, mouth guard, eye guard)?

10.

Have you had any problems with your eyes or vision?

Do you wear glasses or contacts or protective eye wear?

11.

Have you ever sprained/strained, dislocated, fractured, broken or had repeated swelling of any bones or joints?

_____ Head

_____ Knee

_____ Back

_____ Shoulder

_____ Chest

_____ Wrist

_____ Thigh

_____ Forearm

_____ Ankle

_____ Neck

_____ Shin/Calf

_____ Hip

_____ Elbow

_____ Foot

_____ Hand

12.

Have you ever had any other medical problem (infectious mononucleosis, diabetes)?

13.

Have you ever had a medical problem since your last evaluation?

14.

When was your last tetanus shot?

When was your last measles shot?

15.

When was your first menstrual period?

When was your last menstrual period?

When was the longest time between your periods last year?

Please explain “yes” answers here:

I herby state that, to the best of my knowledge, my answers to the above questions are correct.


Signature of Athlete	Signature of Parent/Guardian	Date

Signature of Coach	School

MED-01

General Physical Education

Examiner:

Height _______________ Weight ______________ BP __________/__________ Pulse__________

Vision R 20/_____ L 20/_____ Corrected? _____ Yes _____ No Pupils __________

	Normal	Abnormal Findings
Ears, Nose, Throat
Heart
Chest/Lungs
Skin/Lymphatic
Abdominal
Genitalia/Hernia

Musculoskeletal Examination

Examiner:

	Normal	Abnormal Findings
Neck/Back
Upper Extremities
Lower Extremities
Flexibility

Optional Lab

Urine Sugar __________

Urine Protein _________

Urine Hematest _______

Official Recommendation

A. This athlete _____ may _____ may not compete in athletics based on the data gathered from this exam.

B. Prior to participation, treatment or follow-up on the following in recommended:

C. Recommend further consultation with _______________________________________________________

Signature of Physician: ____________________________________________________ Date: ____________