ࡱ> LNKy 0bjbjEE .@''(rr,-     c-e-e-e-e-e-e-.Z1e-e-  z-www  c-wc-wwrs"Ts# BR-"O--0-"42'F42s#42s# h^wLe-e-m -42r {: EMERGENCY CARD DHS ATHLETIC DEPARTMENT ONLY (Kept securely by the coach at all times) Please Print Cleared/Not Cleared for Contact Sports/Non-Contact Sports on PE Date_________ Signature School Nurse Reviewing PE____________________ Date__________ Athletes Name_______________________________________ Date of Birth________ Home Phone_____________ last first middle Address_______________________________________Grade___Season_____________Sport_____________ List at least 4 and number 1st, 2nd, 3rd, 4th to call for illness or emergency. __Mother_________________________ ____________ _____________ ___________ ________________ name home phone cell phone work phone work town __Father _________________________ ____________ _____________ ___________ ________________ name home phone cell phone work phone work town __Neighbor_______________________ ____________ _____________ ___________ ________________ name home phone cell phone work phone home address __Other__________________________ ____________ _____________ ___________ ________________ name home phone cell phone work phone relationship Family Physician: (1st choice)_________________________________________ Phone___________________ Hospital of choice: (2nd choice)________________________________________ Phone___________________ __Stamford Family Dentist _____________________________________________________ Phone___________________ __Norwalk Information for Health Care Providers in case of Emergency: Please check all that apply here and on back: __No __Yes Allergic to:_____________________________________________ Usual treatment___________________________ __No __Yes Medications (taken at school or home)_____________________________Used for:________________________________ ______________________________________________________________________________________________ __No __Yes Other health issue(s) which may affect athlete in school, sports, or on trips:_________________________________________ Please read below and complete other side DARIEN HIGH SCHOOL ATHLETIC TRAINING RULES Participation in the Darien High School Athletic Program is both an honor and a privilege and, as such, carries a responsibility for the athlete to follow departmental rules and regulations including the following: Training Rules: Any use, involvement with*, or possession of drugs (including anabolic steroids), alcohol, or use of any form of tobacco at any time during the season, on or off campus, will result in appropriate disciplinary action. *Involvement with such substances shall be broadly construed, and it shall include, but is not limited to the following situations: A. Personal possession or use of such drugs, alcohol or tobacco, at any time at any place; or Being in a motor vehicle when alcohol or drugs are present, regardless of whether the student is the passenger or driver or whether the student is in personal possession of any such alcohol or drugs, or Permitting the illegal consumption of alcohol or use of drugs in your home or on your premises. D. Being in a building or on premises or otherwise in the company of others, including but not limited to fellow students, when alcohol or drugs are/have been used or possessed illegally. If you find yourself in such a situation, you are expected to leave the site or company of others immediately. If it is clearly not responsible to do so, you must leave as soon thereafter as possible (In any event, you are responsible for the behavior of others on your home premises). The appropriate disciplinary action under these training rules is separate from any discipline that may otherwise be imposed by the Administration. Disciplinary action under these rules will be determined by consideration of all the facts and circumstances of a particular situation, but shall include as a minimum the following penalties: First Offense: Drugs/Alcohol/Anabolic Steroids: the athlete will be suspended from interscholastic competition for two weeks. Tobacco: the athlete will be suspended for one game. Subsequent Violations: a second drug, alcohol, anabolic steroid, or tobacco violation during a school year will result in the athlete being dropped from the team for the balance of the season. Enforcement Procedures: Darien High School athletes and their parents shall sign an acknowledgement (see reverse side) of these training rules before each athletic season to verify their understanding of and agreement with the terms of these training rules relative to drug/alcohol/tobacco use. Parents will be notified if a training rule is violated and of the disciplinary action taken. The Director of Athletics is responsible for the administration and enforcement of the Darien High School Athletic Training Rules and his/her determination under these rules shall be final. Revised January 29, 2007 Students Name__________________________________________ Date of Birth_____________________ For the relief of pain, I ___do ___do not give my consent for the school nurse or her designate to give acetaminophen (Tylenol). Emergency Medical Authorization: 1. I ___do ____do not give my consent for the school to call a school physician if the physicians I list cannot be reached. 2. If reasonable attempts to contact me or the other names listed have been unsuccessful: _____ I do give my consent for the administration of any emergency treatment necessary by the available licensed medical personnel. This consent does not cover major surgery unless the medical opinions of two other licensed physicians or dentists are obtained prior to the performance of such surgery. OR _____I do not give my consent for any emergency treatment for my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to:______________________________________________________________________. Authorization for Physician to fax school or sports physical forms: I hereby ____do ___do not authorize my childs health care provider __________________________________________ to release information/records to the school nurse or her designate at Darien High School, consisting of health assessment data and immunization records, as required by : 1) General Statutes (CGS) 10-206, mandated health assessment for school entry, grade 6, and grade 10, 2) CGS 10-204 mandated immunizations for school attendance, and/or 3) Connecticut Interscholastic Athletic Conference (CIAC) mandated health assessment for sports participation (High School only). This information will be used to permit the student to attend school and/or participate in interscholastic sports as well as to promote safety for the student and school community within the educational program, including academic and extracurricular activities.This authorization is valid beginning July 1 and will expire on June 30 of this school year. I understand that I may revoke this authorization at any time by submitting written notice of the withdrawal of my consent. I recognize that health records, once received by the school district, will become education records protected by the Family Educational Rights and Privacy Act (FERPA) rather than the HIPAA Privacy Rule. I also understand that my childs ability to obtain health care will not be affected if I do not authorize this release. _______________________________ _______________________________________ ______________________________ Printed Name of Parent or Guardian Signature Date .. DARIEN HIGH SCHOOL ATHLETIC DEPARTMENT Authorization for Athletic Participation: I/We give permission for ______________________________________to participate in the Darien High School Interscholastic Athletic Program. I/We realize that such activity involves the potential for injury which is inherent in all sports. I/We acknowledge that even with the best coaching, use of the most advanced protective equipment and a strict observance of rules, injuries are still a possibility. On rare occasions, these injuries can be severe. Training Rules: I/We have received a copy of the Athletic Handbook and have read, understand, and accept the Training Rules of the Darien High School Athletic Program a synopsis is on the reverse side of this card. 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