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Athletic Permission Form

Form for participation in athletic events.

Please complete the form below. Required fields marked with an asterisk *

Which sports does your student wish to participate in for the current season?
Answer Required
Summer
Fall
Winter
Spring
Baseball
Basketball
Bowling
Cheerleading
Football
Golf
Soccer
Summer Practice
Softball
Track
Volleyball
Wrestling

Student Information

Gender*
Answer Required
Grade Level*
Answer Required

Parent Information

Relationship*
Answer Required
Primary Phone Type*
Answer Required
Secondary Phone Type
Answer Required

ATHLETE ADDRESS

State*
Answer Required

HEALTH HISTORY UPDATE

Since the last preparticipation physical examination, has your son/daughter:

Been medically advised not to participate in a sport?*
Answer Required
Sustained a concussion, been unconscious or lost memory from a blow to the head?*
Answer Required
Broken a bone or sprained/strained/dislocated any muscle or joints?*
Answer Required
Fainted or “blacked out?”*
Answer Required
Experienced chest pains, shortness of breath or “racing heart?”*
Answer Required
Has there been a recent history of fatigue and unusual tiredness?*
Answer Required
Been hospitalized or had to go to the emergency room?*
Answer Required
Since the last physical examination, has there been a sudden death in the family or has any member of the family under age 50 had a heart attack or “heart trouble?"*
Answer Required
Started or stopped taking any over the counter or prescribed medications?*
Answer Required
Been diagnosed with Coronavirus (COVID-19)?*
Answer Required
If diagnosed with Coronavirus (COVID-19), was your child symptomatic?*
Answer Required
If diagnosed with Coronavirus (COVID-19), was your child hospitalized?*
Answer Required
Has any member of the student-athlete's household been diagnosed with Coronavirus (COVID-19)?*
Answer Required

PHYSICAL ON FILE

A valid physical must have been obtained within the past 365 days before the start of the season. If no, one must be obtained prior to participation.

Does your child have a valid physical on file in the Nurse's office?*
Answer Required
Is the student a Transfer Student*
Answer Required

INDEMITY

I hereby give my consent for the above named student to: (1) represent his or her school in athletic activities; (2) accompany any school team of which s/he is a member on any of its local or out-of-town trips; (3) have a thorough medical examination; (4) participate in the year-long weight room training program. Since the physical examination may require the student to "loosen, open or remove their clothing above the waist in a manner to facilitate inspection and examination" parents may be present at the school-based physical exam. In the absence of a parent or guardian, the nurse or a female coach/teacher will be present for a female student, and a male coach/teacher will be present for a male student (N.J.S.A. 18A:40-5). I realize that athletic activities involve the potential for injury, which is inherent in all sports. On rare occasions these injuries can be so severe as to result in total disability, paralysis or even death. I understand that even with the best coaching, use of the most advanced protective equipment, and strict observance of rules, injuries are still a possibility. Therefore, I agree to hold harmless and save the Board of Education of Passaic County Manchester Regional High School District against any claim for damages as the result of any injury which may be sustained while participating. I acknowledge that I have read and understand this warning. I further acknowledge that all equipment issued to student athletes is the property of the Board of Education of Passaic County Manchester Regional High School District and is to be returned at the end of the particular interscholastic athletic competition season, or when requested by the coach or the Athletic Director, whichever comes first. Finally, this request to compete in interscholastic athletics for Manchester Regional High School is entirely voluntary on the student athlete's part, and is made with the understanding that s/he has not violated any of the eligibility rules and regulations of the NJSIAA or the District.*
Answer Required

NJSIAA CONCUSSION POLICY ACKNOWLEDGEMENT FORM

In order to help protect the student athletes of New Jersey, the State of New Jersey and the NJSIAA have mandated that the Manchester Regional High School District, and all Manchester Regional High School student athletes, parents/guardians and coaches follow the Manchester Regional High School Concussion Management Policy.

School Regulation: Click Here
School Policy:         Click Here
School Regulation: Click Here

Please click all confirming you have read and understand the NJSIAA and Concussion Management Policy:*
Answer Required
Please click all confirming you have read and understand the NJSIAA and Concussion Management Policy:*
Answer Required
Please click all confirming you have read and understand the NJSIAA and Concussion Management Policy:*
Answer Required

SUDDEN CARDIAC DEATH IN YOUNG ATHLETES

All student athletes and their parents need to read and become familiar with the Sudden Cardiac Death in Young Athletes brochure.

Sudden Cardiac Death: Click Here

Please click the box below confirming your have read the Sudden Cardiac Death in Young Athletes Brochure:*
Answer Required

SPORTS RELATED EYE INJURIES

All student athletes and their parents need to read and become familiar with Sports Related Eye Injuries materials.

Eye Injurey Flier: Click Here

Please click the box below confirming your have read the Sports Related Eye Injury flier:*
Answer Required

NJSIAA STEROID TESTING POLICY CONSENT TO RANDOM TESTING

In Executive Order 72, issued December 20, 2005, Governor Richard Codey directed the New Jersey Department of Education to work in conjunction with the New Jersey State Interscholastic Athletic Association (NJSIAA) to develop and implement a program of random testing for steroids, of teams and individuals qualifying for championship games.

Beginning in the Fall, 2006 sports season, any student­athlete who possesses, distributes, ingests or otherwise uses any of the banned substances on the attached page, without written prescription by a fully­licensed physician, as recognized by the American Medical Association, to treat a medical condition, violates the NJSIAA’s sportsmanship rule, and is subject to NJSIAA penalties, including ineligibility from competition. The NJSIAA will test certain randomly selected individuals and teams that qualify for a state championship tournament or state championship competition for banned substances. The results of all tests shall be considered confidential and shall only be disclosed to the student, his or her parents, and his or her school. No student may participate in NJSIAA competition unless the student and the student’s parent/guardian consent to random testing.

By signing below, we consent to random testing in accordance with the NJSIAA steroid testing policy. We understand that if the student or the student’s team qualifies for a state championship tournament or state championship competition, the student may be subject to testing for banned substances.

Banned Drugs: Click Here

Steroid Testing Policy: Click Here

Please click the box below confirming your have read the Banned Drugs Policy*
Answer Required
Please click the box below confirming your have read the Steroid Testing Policy*
Answer Required

OPIOID FACT SHEET

This sign-off sheet is due to the appropriate school personnel as determined by your district prior to the first official practice session of the spring 2018 athletic season (March 2, 2018, as determined by the New Jersey State Interscholastic Athletic Association) and annually thereafter prior to the student-athletic's or cheerleader's first official practice of the school year.

Fact Sheet: Click Here

Please click the box below confirming your have read the Opioid Fact Sheet:*
Answer Required

PARENT STUDENT HANDBOOK

All student athletes and their parents need to read and become familiar with the rules and requirements for extracurricular sports programs as outlined in the Parent­ Student Handbook.

Student Handbook: Click Here

Please click the box below confirming your have read the Parent Student Handbook:*
Answer Required

TRANSPORTATION PERMISSION

I hereby grant permission for my child to travel privately to practice/games. My child may travel by private car if the driver is the holder of a valid license. It is understood by the undersigned that the school authorities and coaches are absolved from any liability for accidents that might occur on the way to and from, or at the place of destination.

Please click the box below confirming you agree with the above statement.*
Answer Required

Emergency Contact

Please complete the information below; this information will be given to the coach in case of an emergency.

Parent or Guardian One

Parent or Guardian Two

In an Emergency, if parents cannot be contacted, please notify:

Prefered Hospital

DECLARATION

I declare to my understanding and concurrence with the information completed in the Sports Permission Packet, which includes: Supplemental Health and Permission Form, Sudden Cardiac in Youth, Sports Related Eye Injuries, Steroid Consent to Random Testing, Concussion Policy, Transportation Permission, Opioid Fact Sheet, Emergency Information form, Athletic Release.

Please click the box below confirming you agree with the above statement.*
Answer Required

DIGITAL SIGNATURE

By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By selecting "I Accept" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforce ability of your E-Signature or any resulting agreement between you and MRHS. You are also confirming that you are the student authorized to enter into this Agreement. You further agree that each use of your email equates to your E Signature and constitutes your agreement to be bound by the terms and conditions of these Disclosures and Agreement as they exist on the date of your E-Signature on this form.*
Answer Required
Confirmation Email