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Athletic Waiver Form Winter 2023-2024

TAUNTON HIGH SCHOOL ATHLETIC DEPARTMENT

AUTHORIZATION FOR MEDICAL TREATMENT

EMERGENCY INFORMATION

I give my permission for the evaluation/treatment of ________________

Student First Name*

Answer Required

Student Last Name*

Answer Required

by any duly Licensed physician and/or hospital facility in the event of illness or injury. I also authorize transportation in an ambulance if necessary.

Sport*

If sport is not available please contact athletic department:

Answer Required

Click YES to confirm you are the parent/guardian.*

Answer Required

YES

Parent/Guardian Signature*

Answer Required

Date*

Answer Required

Athletes Address and Information

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

State*

Answer Required

Date of Birth:*

Answer Required

Age:*

Answer Required

Grade*

8-9-10-11-12

Answer Required

Parent/Guardian Contact Information

Parent/ Guardian Name:*

Answer Required

Telephone #:*

Answer Required

Cell #:

Answer Required

Alternate Emergency Contact Person:*

Answer Required

Relationship*

Answer Required

Telephone # (s)*

Answer Required

Please answer the following medical history questions:

Please check yes if the athlete has had a Concussion.*

Answer Required

Yes

Please provide information including dates relative to any head injury history

Answer Required

Please check if the athlete has any of the following:

Answer Required

Diabetes

Epilepsy

Heart Condition

Asthma

Other:

Diabetic students must have glucose tablets and a glucometer present at all practices and games.
Asthmatic students must have inhaler present at all practices and games.
All athletes must report any medical changes to the Athletic Director’s Office and the Athletic Trainer.

Please list ALL medications, including inhalers and directions for use:

Answer Required

Please list ALL allergies, including medications, food and insects:

Answer Required

Please provide all insurance information below:

Policy Name*

Answer Required

Policy Number*

Answer Required

Subscribers Name*

Answer Required

If you need to obtain the Additional Voluntary Insurance offered by the Taunton School Department’s Athletic Insurance Policy please check here and an enrollment form will be sent home with your student athlete.

Answer Required

Yes

I, ____________________________,*

Father/Mother/Guardian Name

Answer Required

the undersigned Father/Mother/Guardian of _____________________________*

Students Name

Answer Required

a minor, do hereby consent to his/her participation in voluntary athletic programs and do forever RELEASE, acquit, discharge and covenant to hold harmless the City of Taunton, the Taunton School District, Taunton High School and any employees or agents of said City, District, and High School from any and all actions, causes of action and claims on account of, or in any way growing out of, directly or indirectly, all known and unknown personal injuries or property damage which I may now or hereafter as the parent/guardian of said minor, and also all claims or right of action for damages which said minor has or hereafter may acquire, either before or after he/she has reached his/her age of majority resulting from his/her participation in the Taunton Public Schools Physical Education Department’s Athletic Program.

I have read the above statement and agree to its terms.

Click YES to confirm you are the parent/guardian.*

Answer Required

YES

Parent/Guardian Signature*

Answer Required

Date:*

Answer Required

Copy of physical within 13 months mandatory to try out for any team at THS: Please upload child's physical if electronic copy is available: Convert pictures into PDFs when possible

Answer Required

Choose a file or drag it here.

Implicit Bias Course/Diversity, Equity and Inclusion Pledge

Implicit Bias Course: https://nfhslearn.com/courses/implicit-bias

As a student-athlete of a Massachusetts Interscholastic Athletic Association member school, I agree to abide by all guidelines regarding the use or exhibition of discriminatory practices.

I PLEDGE TO:

1. Help create and foster a safe environment within the school community, which includes the responsible use of social media.

2. Consistently model respect and tolerance by setting an example of good sportsmanship and positive behavior, including language (body and spoken), gestures, signs, and overtures.

3. Not enable my fellow student-athletes who use abusive language, signs, gestures, or overtures. I will not cover up for them or lie for them if any rules are broken.

4. Hold myself, my fellow student-athletes, and our community responsible and accountable for their actions.

5. Seek information and assistance in dealing with my own or my fellow student athlete’s negative behaviors, problems, or concerns.

6. Be open and honest with my coach and other school personnel when the best interest of myself, my fellow student-athletes, and my school are being jeopardized.

7. Thrive to create a school without hate.

8. Support the Diversity, Equity, and Inclusion, Sportsmanship and Game Officials Committees’ policy/programs within the MIAA, Taunton High School, and all school functions.

I have completed the Implicit Bias Course and agreed to the Diversity, Equity, and Inclusion Pledge.

*************************************************************************

Compromiso de Diversidad, Equidad e Inclusión

Como estudiante-atleta de una escuela miembro de la Asociación Atlética Interescolar de Massachusetts, me comprometo a respetar todas las normas relativas al uso o exhibición de prácticas

discriminatorias.

ME COMPROMETO A:

1. Ayudar a crear y fomentar un entorno seguro dentro de la comunidad escolar, lo que incluye el uso responsable de las redes sociales.

2. Mostrar constante respeto y tolerancia, dando ejemplo de comportamiento positivo, incluyendo el lenguaje (corporal y hablado), los gestos, las señales e insinuaciones.

3. No permitir que mis compañeros estudiantes-atletas usen un lenguaje abusivo, señales, gestos, o insinuaciones. No los encubriré ni mentiré por ellos si se infringe alguna norma.

4. Responsabilizarme a mí mismo, a mis compañeros estudiantes-atletas y a nuestra comunidad de sus acciones.

5. Buscar información y ayuda para afrontar mi comportamiento negativo, problemas o preocupaciones o el de mis compañeros atletas.

6. Ser abierto y honesto con mi entrenador y el resto del personal de la escuela cuando se pongan en peligro mis intereses, los de mis compañeros y los de la escuela.

7. Esforzarme por crear una escuela sin odio.

8. Apoyar la política/programas de los Comités de Diversidad, Equidad e Inclusión, Deportividad y Oficiales de Juego de la MIAA, la Escuela Secundaria de Taunton, y todas las funciones de la escuela.

Completé el Curso de sesgo implícito y acepté el Compromiso de diversidad, equidad e inclusión.

Electronic signature* *

Signatory must be 18 years of age

Answer Required

Yes, I Agree to the Implicit Bias Course/Diversity, Equity and Inclusion Pledge

*************************************************************************

NFHS Learn Concussion Course: https://nfhslearn.com/courses/concussion-for-students

Electronic signature* *

Signatory must be 18 years of age

Answer Required

Yes, I have watched the NFHSLearn Concussion Course

Fax a copy of physical if not able to electronically submit at 508-821-1149.

Athletic Fee is $150 for all 3 seasons to be paid after teams are made.

Confirmation Email

Confirmation Email *

Email Required

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