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.
Emergency Contacts (In Order of Contact)
(Where your child’s/ward’s condition is confidential or requires further explanation, you are requested to contact your child’s/ward’s coach.)
Is your child/ward allergic to any drugs, food or medication/other?
Does your child/ward wear a medical alert bracelet?
Does your child/ward wear a neck chain?
Does your child/ward carry a medical alert card?
Does your child/ward wear eyeglasses?
Does your child/ward wear contact lenses?
Does your child/ward wear an orthodontic appliance?
Does your child/ward have dental restorations (that is, crowns, bridges)?
Indicate if your child/ward has been diagnosed as having any of the following medical conditions and provide relevant details:
Does your child/ward take any prescription drugs?
Indicate any physical ailments that apply and provide relevant details:
Has your child/ward previously been diagnosed with a concussion?
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.
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.
Acknowledgement of Risks/Request to Participate/Informed Consent Agreement
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.