Dorchester County Athletic Participation Form-CSDHS

Dorchester County Athletic Participation Form-CSDHS
Athlete:
Athlete's Name*

FirstLast
Grade*
Graduation Year*
Gender*
Age*
Date of Birth*

MonthDayYear
Fall Sport(s) (check all that apply)

CheerleadingCross CountryFootballGolfBoys SoccerGirls SoccerUnified Tennis
Winter Sport(s) (check all that apply)

Boys BasketballGirls BasketballIndoor TrackSwimmingUnified Weight TrainingWrestling
Spring Sport(s) (check all that apply)

BaseballBoys LacrosseGirls LacrosseSoftballTrack and FieldTennisUnified Bocce
Athlete's Mailing Address*

Address

Street Address Line 2

CityState

Zip Code
Athlete's Home Phone
Athlete's Cell Phone*
Athlete's E-mail*
Is your athlete enrolled in CSD Wellness?*

YesNo
If no, would you like to receive more information?

YesNo
Athlete's Guardian(s):
Guardian's Name*

FirstLast
Relationship*
Is Guardian's Mailing Address the same as Athlete's Address?

YesNo
Mailing Address*

Address

Street Address Line 2

CityState

Zip Code
Guardian's Home Phone
Guardian's Cell Phone*
Guardian's E-mail*
Guardian #2's Name

FirstLast
Relationship
Is Guardian's Mailing Address the same as Athlete's Address?

YesNo
Mailing Address *

Address

Street Address Line 2

CityState

Zip Code
Guardian #2's Home Phone (IF DIFFERENT FROM ABOVE)
Guardian #2's Cell Phone
Guardian #2's E-mail
Emergency Contact:

(If named above guardians cannot be reached, who may we contact in case of emergency?)
Emergency Contact Name*

FirstLast
Relationship*
Mailing Address*

Address

Street Address Line 2

CityState

Zip Code
Home Phone
Cell Phone*
Health Insurance Information
Insurance - Please choose one*

My child has health insurance and I do not wish to buy school insurance.I do NOT have insurance and MUST buy school insurance.I have my own insurance and still wish to buy school insurance.
Company Name*
Policy/Member ID #*
Group #
Click here to enroll

You will be given a policy# once enrolled- please enter it below.
Policy # given to you by K&K Insurance
Primary Care Doctor
Physician's Name*
Clinic Name
Address*

Address

Street Address Line 2

CityState

Zip Code
Phone #*
Fax #
Date of student athlete's most recent physical?

MonthDayYear
Medical History
Please check any medical conditions your student athlete has suffered from. Then use the box following to explain the conditions.
NONEAlcohol/Drug AbuseAllergiesAnger OutburstsAnorexiaAsthmaAttention Deficit DisorderBleeding ProblemsCancerChickenpoxChronic Joint ConditionsDehydrationDepressionDiabetesEar InfectionEpilepsy/SeizuresHeadaches (frequent)HearingHeart Problems /Murmur/ Rheumatic FeverHepatitisHIVLearning DisabilitiesMalnutritionPneumoniaSickle CellSurgeryTuberculosisVision Problems
Explain the conditions.*
Medications
Does the student athlete take any type of medication(s)?*

YesNo
Please list any medications your child takes on a daily and/or as needed basis. Include name of medication, dosage, and how often it is taken.*
In case of emergency, I give permission for my son/daughter to be treated by AthleticTraining Staff, Doctor, or hospital staff.

YesNo
Concussion Reporting
Has your child ever sustained a concussion or suffered from a brain injury?*

YesNo
Please list the dates of injury starting with the nost recent. Please include the duration of symptoms and major symptoms to the best of your ability.*
Other Important Information
Please include any other information you deem necessary for the Athletic Trainer or medical staff to be knowledgeable of below:
INFORMATION YOU NEED TO KNOW
Dorchester County Athletic Philosophy
The Dorchester County Public School (DCPS) system seeks to provide an athletic program that is beneficial for all athletes and one that provides an opportunity to learn skills, learn good sportsmanship, and build strong character. Through participation in DCPS athletic programs, it is hoped that the following goals are successfully attained:

* Build self-discipline and establish team and personal goals for success

* Strive for academic excellence

* Promote understanding and tolerance for individuals with different skill levels

* Establish appropriate physical and mental health habits that result in success
Sportsmanship – Code of Conduct
Sportsmanship – Code of Conduct

One of the main goals of the athletic program is to teach the concept of sportsmanship. Good sportsmanship requires that every person be treated with respect. This includes oneself, teammates, coaches, referees, and members of the opposing team.

All schools in the Bayside Conference are evaluated in regards to their sportsmanship. Each year the school receiving the highest score in the North and the South receive a banner to hang in their school recognizing them for outstanding sportsmanship.

Dorchester County Schools are requiring parents and players to sign this Sportsmanship Code of Conduct acknowledging that they understand the importance of good sportsmanship and are willing to act in an appropriate manner during athletic contests. Unsportsmanlike conduct may result in sanctions which could include removal from the contest, dismissal from the team, or being barred from attending future athletic contests.
My athlete and I have read and understand the Dorchester County Athletic Philosophy and Sportsmanship-Code of Conduct.*

Yes
Concussion Awareness
I acknowledge that I have received information on all of the following: -The definition of a conucussion -The signs and symptoms of a concussion to observe for or that may be reported by my ahtlete -How to help my athlete prevent a concussion -What to do if I think my ahtlete has a concussion, specifically, to seek medical attention right away, keep my athlete out of play, tell the coach about a recent concussion, and report any concussion and/or symptoms to the school nurse*

Yes
My student athlete has read and understands "Heads Up, Concussion in High School Sports?"*

Yes
I have read and understand "Graduated Return to Play Protocol?"*

Yes
Forms to be completed and returned to your Athletic Trainer
I acknowledge that the following forms must be completed in order for my student athlete to participate in high school sports at CSDHS. These forms can be printed out or obtained by the athlete's coach or athletic trainer.*

Yes
Parent Signature

Clear
It is our mission to provide the students of Cambridge-South Dorchester with a variety of programs in a safe and caring environment where we will enable them to be successful in any post-secondary endeavor. Through these programs, students will become productive citizens as we help them develop intellectually, personally, socially, ethically and physically. Cambridge-South Dorchester will serve the community as a center for educatinal, artistic, and athletic programs, gatherings and meetings.
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Dorchester County Athletic Participation Form-CSDHS

Athlete:

Athlete's Guardian(s):

Health Insurance Information

Primary Care Doctor

Medical History

Concussion Reporting

Other Important Information

INFORMATION YOU NEED TO KNOW

Dorchester County Athletic Philosophy

Sportsmanship – Code of Conduct

Sportsmanship – Code of Conduct

Concussion Awareness

Forms to be completed and returned to your Athletic Trainer