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Homeschool Sports Day

Open to all Homeschoolers ages 12 -17

 Sports Day Home Page         Fees             schedule            Location    

Registration Form     Medical Information Form
 
Please mail Registration and Medical forms and annual fees to :
Nancy Cloutier
16122 Coral Bay
Crosby TX 77532                  

 

 
Homeschool Sports Program
Medical Information

Name of Children:                 _________________________________________

_________________________________________

_________________________________________

In consideration of my child's participation in the Homeschool Sports Day program: I hereby authorize, in the event my child suffers injury, any director, coach, medical attendant, or adult leader of the Homeschool Sports Day program to consent to emergency medical treatment for my child when I cannot be contacted to so consent. Such medical treatment may include, without limitation, x-ray examination, anesthetic, medical, surgical examination or treatment and general hospital care. No prior determination of life threatening emergency or danger of serious or permanent injury resulting from delay of treatment need be made under this authorization. EXCEPT AS NOTED BELOW, this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, and is given to provide authority and power on the part of a supervisor or medical attendant of the Homeschool Sports Day program to give specific consent to any and all such examination, treatment, or hospital care.

Except as indicated below, I specifically give my consent for first aid treatment with bandages and antibiotic ointment (Neosporin, Neomycin, Mycitracin, Bacitracin, and/or Polymyxin), Hydrogen Peroxide, Rhuligel, Vaseline, Ibuprofen, and/or Tylenol. Homeopathic remedies (arnica gel, calendula cream,) are available as well.

EXCEPTIONS:______________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

I and my child hereby release, absolve and hold harmless the directors, coaches, medical attendant, and adult leaders of the Homeschool Sports Day program, and the facility where it is held, from any and all liability for all losses, damages or injuries occurring as a result of my child's participation in the association’s activities. I further agree to make or cause to be made, by assignment of third party benefits or otherwise, full and complete payment for examination, treatment or hospital care required in the case of a medical emergency.

I understand that reasonable precautions will be taken to make the program safe and beneficial for all children, but that risk of injury cannot be eliminated entirely, and that this release is necessary for my child to participate in the Homeschool Sports Day program.

I hereby verify that I understand and accept the terms of this Authorization, and that my child is in good

physical condition and not limited to participate in any physical activities of the Homeschool Sports Day program except as noted on the back.

 

Signature of Parent or Legal Guardian:_________________________________________________________ Date: ____________________

 continued on next page

 

 

STUDENT INFORMATION Please Print Legibly!

Please put ‘“NONE” OR “N/A” when NOT APPLICABLE

1. STUDENTS

NAME:___________________________________ AGE______ BIRTHDATE______ /_____ /______ SEX: ________

NAME:___________________________________ AGE______ BIRTHDATE______ /_____ /______ SEX: ________

NAME:___________________________________ AGE______ BIRTHDATE______ /_____ /______ SEX: ________

NAME:___________________________________ AGE______ BIRTHDATE______ /_____ /______ SEX: ________

ADDRESS: __________________________________________________________________________________

CITY ______________________________________ STATE ________ ZIP ____________________

FAMILY PHONE   (___ _)______________________ CELL  (___ )__________________________ .

MEDICAL INFORMATION: Please indicate any special limitations, problems, or needs of each student (e.g. existing illness, previous injuries, handicaps, allergies to drugs, limitations on physical activities) Children with Asthma should bring their medication. Additional information may be required for asthmatic children. Please see the first aid person to be sure.

STUDENT: _________________________________________________________________________________________

STUDENT: _________________________________________________________________________________________

STUDENT: ________________________________________________________________________________________

STUDENT: _________________________________________________________________________________________

2. MOTHER’S NAME:_______________________________________________________________________________

ADDRESS (If Different)_______________________________________________________________________________

CITY ___________________________________________ STATE_____________ ZIP ______________________

HOME PHONE (____)________________________ WORK (___ _)______________________ CELL(___ )_______________ .

MOTHER’S EMAIL__________________________________________________________________________________

3. FATHER’S NAME:________________________________________________________________________________

ADDRESS (If Different)_______________________________________________________________________________

CITY __________________________________________ STATE______________ ZIP ________________________

HOME PHONE  (____)________________________ WORK (___ _)______________________ CELL(___ )_______________ .

FATHER’S EMAIL__________________________________________________________________________________

4. INSURANCE COMPANY (not required to participate): __________________________________________________

EMPLOYER OF POLICY HOLDER: _________________________________________________________________

POLICY NO: ______________________________________________________________________________________

5. PHYSICIANS NAME ________________________________________________________________________

PHYSICIAN'S PHONE (____)________________________  PHYSICIAN'S HOSPITAL ____________________

6. PERSON TO CONTACT, OTHER THAN PARENT, IN CASE OF EMERGENCY___________________________

HOME PHONE  (____)________________________ WORK (___ _)______________________ CELL(___ )_______________ .

 

Homeschool Sports Day

email:  ncloutier3@hotmail.com