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Sample Interschool Medical Information and Consent to Participate Form

This sample form is intended to serve as a guide for stakeholders to create a form that aligns with the policies and procedures in their respective school division/school.

 

PLEASE NOTE: FREEDOM OF INFORMATION - The information provided on this form is collected pursuant to the school division's education responsibilities as set out in the Education Act and its regulations. This information is protected under the Freedom of Information and protection of privacy act and will be utilized only for the purposes related to the Division's policy on Risk Management for Interschool Athletics. Any questions with respect to this information should be directed to your school principal.

Parents/Guardians are requested to complete the Interschool Medical information and Consent to Participate Form and return it to the appropriate school personnel.

Please Note: the student is ineligible to participate in practices or competitions without first providing teacher/coach with the completed form.

Student Name:
Coach:
Activity:
Student Date of Birth: [YY/MM/DD)

Emergency Contacts (In Order of Contact)

Name of 1st contact:
Relationship to athlete:
Phone number #1:
Phone number #2:
Email address:
Name of second contact:
Relationship to athlete:
Phone number #1:
Phone number #2:
Email address:
Name of 3rd contact:
Relationship to athlete:
Phone number #1:
Phone number #2:
Email address:
Physician name:
Physician phone number:

(Where your child’s/ward’s condition is confidential or requires further explanation, you are requested to contact your child’s/ward’s coach.)

Date of last complete medical examination:
Date of last tetanus immunization:

Is your child/ward allergic to any drugs, food or medication/other?

Yes
No
If yes, provide details:
Medic Alert Information

Does your child/ward wear a medical alert bracelet?

Yes
No

Does your child/ward wear a neck chain?

Yes
No

Does your child/ward carry a medical alert card?

Yes
No
If yes, please specify what is written on it:
Oral and Visual Appliance

Does your child/ward wear eyeglasses?

Yes
No

Does your child/ward wear contact lenses?

Yes
No

Does your child/ward wear an orthodontic appliance?

Yes
No

Does your child/ward have dental restorations (that is, crowns, bridges)?

Yes
No
Medical Conditions

Indicate if your child/ward has been diagnosed as having any of the following medical conditions and provide relevant details:

Allergies
Anaphylaxis
Asthma
Deafness
Epilepsy
Heart disorders
Type I Diabetes
Type II Diabetes
Other:
Relevant details:
Medications

Does your child/ward take any prescription drugs?

Yes
No
If yes, provide details:
What medication(s) should be accessible during the sport activity?
Who should administer the medication?
Physical Ailments

Indicate any physical ailments that apply and provide relevant details:

Arthritis or rheumatism
Chronic nosebleeds
Dizziness
Fainting
Headaches
Hernia
Orthopaedic conditions
Spinal conditions
Swollen, hyper-mobile or painful joints
Trick or lock knee
Relevant details:
Concussion

Has your child/ward previously been diagnosed with a concussion?

Yes
No
How many times?
When was the last diagnosis? [month/day/year]
What medical advice was given by a medical doctor/nurse practitioner about participating in future physical activity?

If your child/ward is presently diagnosed with a concussion by a medical doctor/nurse practitioner, that was sustained outside of school physical activity, then documentation must be provided consistent with the school division policy/protocols around concussion recognition and management before the student returns to interschool sport.

Other Conditions

Please indicate any other condition that will limit participation or that the coach should be aware of:
Medical Services Authorization (Optional)

In a situation when emergency medical or hospital services are required by the listed participant, and with the understanding that every reasonable effort will be made by the school/ hospital to contact me, my signature on this form authorizes medical personnel and/or hospital to administer medical and/or surgical services, including anaesthesia and drugs. I understand that any cost will be my responsibility.

Signature of Parent/Guardian:
Date:

Acknowledgement of Risks/Request to Participate/Informed Consent Agreement

I have discussed the signs, symptoms and management of a concussion with my child/ward based on Parachute’s Concussion Guide for Parents and Caregivers: [Initials of Parent/Guardian]
I have read and understand the notices Accident Insurance: [initials of Parent/Guardian]
I request our child/ward to try out/participate on the: [insert team name]
during [year] school year.

I hereby acknowledge that I have read and understand the notice of Elements of Risk in the Interschool Parent/Guardian Letter and accept the risk inherent in the requested activity and assume responsibility for my child/ward for personal health, medical, dental and accident insurance coverage.

Signature of Parent/Guardian:
Date:
Question Mark

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