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Richmond Community Schools
ATHLETE
EMERGENCY INFORMATION FORM
NAME_________________________________________ BIRTHDATE____________
AGE_________
HOME ADDRESS________________________________________
CITY________________________
ZIP_____________
HOME PHONE_________________________________
Parent/Guardian
Name & Daytime Phone Numbers:
FATHER_______________________________/________________________/_____________________
NAME
PHONE #
Alt. Phone #
MOTHER______________________________/________________________/______________________
NAME
PHONE #
Alt. Phone #
****************************************************************************************************
EMERGENCY,
IF PARENTS CANNOT BE CONTACTED, NOTIFY:
NAME______________________________________________
PHONE_________________________
Relationship to student_________________________________
Alt. Phone # _______________________
Family Doctor________________________________________
PHONE__________________________
Preferred Hospital_______________________________
Insurance
Co.____________________ Contract #_______________________________________
***KNOWN
ALLERGIES:
________________________________________________________________________________________
***OTHER
Important Medical
Information:____________________________________________________
________________________________________________________________________________________________
_____NO
_____YES The team
physician and/or coach may apply first aid treatment until the family doctor can be contacted.
_____NO
_____YES We give consent
for coaches, trainers, and team physicians to use their own judgment in securing
medical aid and ambulance service in the event parents cannot be reached.
******************************************************************************
We have read and understand the Richmond Community Schools
Statement of Risk/Code of Conduct for athletes, on the back page of this form,
and by our signatures, indicate our willingness to abide by the code.
___________________________________
______________________________________
Student’s Signature Date
Parent/ Guardian Signature
Date
Richmond Community Schools
Parent/Student Responsibility Statements
Statement of
Risk-Athletic Code of Conduct Consent
Parent/Student Responsibility Statements
1.
Each athlete and parent/legal guardian is responsible for his/her own
insurance program. Richmond Schools
is not responsible for any insurance (this includes use of an ambulance).
2.
Richmond Schools WILL NOT pay medical expenses resulting from bodily
injury to anyone who participates in sports/athletic programs.
3.
I understand the possibility that serious injury or death may result from
participation in athletic activities.
Statement of Risk
Warning: Participation in
supervised interscholastic athletics and activities may be one of the least
hazardous activities in which any student will engage in or out of school.
Participation in interscholastic athletics still includes a risk of
injury which may range in severity from minor to long term catastrophic.
Although serious injuries are not common in supervised athletic programs,
it is impossible to eliminate this risk. Participants
have the responsibility to help reduce the chance of injury.
Players must obey safety rules, report physical problems to their
coaches, follow a proper conditioning program, and inspect equipment daily.
Before being allowed to try out for an athletic team, each athlete
must have an up-to-date physical on file in the athletic office.
This physical must be dated on or after April 15th of the
previous year.
Each athlete must have an
emergency form on file in the athletic office.
Each athlete must pay the pay-to-participate amount.
These forms/fees must be on file in the athletic office by the specified
date, which is set by the athletic director, before he/she will be allowed to
participate in any athletic activity.
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Athletic Code of Conduct Consent
This application to compete in Interscholastic Athletics is entirely
voluntary on my part and is made with the understanding of the risks involved
and that I have not violated
the eligibility rules of the Michigan High School Athletic Association, and that
I will follow all rules and regulations set down by the Richmond School
District, my Coach and Athletic Department.
As a representative of my school, I will conduct myself in an exemplary
manner at all times. I understand
that violation of the previously mentioned rules and regulations or conduct
unbecoming a team member may lead to my dismissal from the team.
We have read and understand the Richmond Community Schools Code of
Conduct for athletes, and by our signatures on the front of this form, indicate
our willingness to abide by the code.
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