Safety Guidelines for Secondary Interschool Athletics in Alberta

APPENDIX B - Sample Secondary Interschool Athletic Activity Student
Athlete Information and Consent Form
This form should be completed on behalf of each team member participating in secondary interschool
athletic activities and returned to the teacher/coach prior to the first competition.
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Student Athlete Name:_______________________________________________________________
Home Phone: ______________________________________________________________________
Home address: _____________________________________________________________________
City:_________________________________________ Postal Code:__________________________
Alberta Health Care #: _______________________________________________________________
Parent/Guardian:____________________________________________________________________
Work Phone #: ____________________________ Cell Phone #: _____________________________
Student Athlete’s Physician: _____________________________________ Phone #: ____________
Emergency Contact Person: ______________________________________ Phone #: ____________
MEDICAL INFORMATION
Date of last complete medical examination: _______________________________________________
NOTE: An annual medical examination is recommended.
Date of last tetanus immunization: ______________________________________________________
Is your son/daughter/ward allergic to any drugs, foods or medication/other? Yes No
If yes, provide details:________________________________________________________________
Does your son/daughter/ward take any prescription drugs? Yes No
If yes, provide details:________________________________________________________________
What medication(s) should the student athlete have on hand during the interschool athletic activity?
___________________________________________________________________________________
Who should administer the medication?___________________________________________________
I, the parent/guardian of (student athlete name), give permission for the teacher/coach to administer this
medication(s) to the student athlete as directed or needed.
Signature: _________________________________________________________________________
Date: _____________________________________________________________________________
Or
Although the student athlete can under normal circumstances administer his/her own medication, I, the
parent/guardian of (student athlete name), give permission for the teacher/coach/teacher to administer
the medication if an injury/illness prevents the student athlete from doing so themselves.
Signature: _________________________________________________________________________
Date: _____________________________________________________________________________
Continuned on next page
Safety Guidelines for Secondary Interschool Athletics in Alberta - February 2012