Athletic Medical Emergency Information Form & Instructions.

INTERSCHOLASTIC ATHLETIC PARTICIPATION INSTRUCTIONS
Prior to the first day of practice, the following must be presented to the Athletic Department.
Summer hours will be posted on the HS website prior to the start of fall sports.
A completed and signed GPS Athletic Emergency Information Form that has been signed off on
by the school nurse. The nurse will only sign off on the Emergency Information Form if a
completed physical examination form is on file in the nurse’s clinic.*
Appropriate Authorization to Administer Medication form and/or appropriate Action Plan, if
applicable.
A signed GMHS Athletic Participation form.
For any previous injury, a statement of clearance from your doctor.
$75 Pay to Participate. Checks made out to GMHS. Additional PTP fees for Football, Swimming
and Hockey.
*The Connecticut Interscholastic Athletic Conference (CIAC) requires every athlete to present a current
physical examination prior to participating in any GPS interscholastic sport. The physical is valid for a
period of 13 months from the date of the exam. STUDENTS WILL NOT BE ALLOWED TO PRACTICE
OR PLAY WITH AN EXPIRED PHYSICAL.
Athletic Emergency Information Form (AEF)- provides pertinent health information related to
participating in sports as well as emergency contact information for the coach and trainer. A new form
must be completed prior to each sport session.
Authorization to Administer Medication Form- If medication information is already on file with the nurse for
the current school year, the school nurse will provide a copy with your AEF. If the school nurse has not
been provided with the appropriate form; the Nurse WILL NOT sign the form granting participation until all
the appropriate medical forms are obtained. *Note: medication order forms and Action Plans expire at
the conclusion of every school year.
.
Students with Asthma/Exercise Induced Asthma: An Asthma Action Plan and or
Authorization to Administer Medication form is to be completed by the physician and
parent and submitted along with the AEF.
Students with Severe Allergies/Anaphylaxis reactions requiring an Epi-Pen and/or
Benadryl must have a Severe Allergy Action Plan (Anaphylaxis) form and or
Authorization to Administer Medication form completed by the physician and parent and
submitted along with the AEF.
Students requiring other medications: An Authorization to Administer Medication form
is to be completed by the physician and parent and submitted along with the AEF.
To assure a smooth start to any sport season, the following procedure must be followed:
1. Students or parents should check in with the school nurse to determine the date of the last
physical exam on file prior to the end of the previous school year to determine eligibility for fall
sports.
2. On the first day of practice, the student athlete will bring to the coach the AEF signed by the
Nurse and other applicable medical forms mentioned above.
The school nurse is available during normal student hours of 7:30 am – 2:30 pm. For summer hours,
check the clinic webpage.
High School Clinic Phone: 860-844-3019 High School Clinic Fax: 860-413-9241
Middle School Phone: 860-844-3038 Middle School Clinic Fax: 860-413-3854

GRANBY MEMORIAL SCHOOL DISTRICT
INTERSCHOLASTIC ATHLETIC EMERGENCY INFORMATION FORM
School year: ___________________ Grade: _________________
___________________ ______________________ ______________________ _________________________ _______________
Season Physical Expiration Sport Nurse Date
Alerts: ___________________________________________
LAST NAME _______________________________________________FIRST _________________________________
DATE OF BIRTH _______________
HOME ADDRESS: ____________________________________________________ ZIP CODE ______________ HOME PHONE _______________________
PREVIOUS ORTHOPEDIC INJURIES YES EXPLAIN: ________________________________________________________________________________
INFECTIOUS MONONUCLEOSIS IN PAST 6 MONTHS: YES DATE___________________________________
HEAT RELATED PROBLEMS YES EXPLAIN _______________________________________________________________________________________
HEART RELATED PROBLEMS YES EXPLAIN _______________________________________________________________________________________
PREVIOUS CONCUSSION OR HEAD INJURY YES EXPLAIN __________________________________________________________________________
OTHER SIGNIFICANT INJURIES OR MEDICAL CONDITIONS: _____________________________________________________________________________
ALLERGIC REACTION TO: _________________________________________________________________________________________________________
EPI-PEN NEEDED:
BENADRYL NEEDED:
NO
NO
ASTHMA OR EXERCISE INDUCED ASTHMA REQUIRING MEDICATION:
YES (Download and submit a completed Anaphylactic Action Plan)
YES (Download and submit a completed Anaphylactic Action Plan)
NO
(Download and submit a completed Asthma Action Plan)
YES
*The School nurse MUST have a current order on file for Authorization to Administer Medication and/or relevant Action Plan.
TAKING MEDICATION: (LIST) _______________________________________________________________________________________________________
ADDITIONAL COMMENTS: __________________________________________________________________________________________________________
___________________________________ _______________________________ ____________________________ ______________________________
MOTHER’S NAME/LEGAL GUARDIAN PHONE NUMBER WORK NUMBER CELL/OTHER NUMBER
___________________________________ ________________________________ ___________________________ _______________________________
FATHER’S NAME/LEGAL GUARDIAN PHONE NUMBER WORK NUMBER CELL/OTHER NUMBER
________________________________________________________________
______________________________________________________________
NAME OF #1 EMERGENCY CONTACT PHONE NUMBER NAME OF #2 EMERGENCY CONTACT PHONE NUMBER
___________________________________ _____________________________ _____________________________ ________________________________
FAMILY PHYSICIAN PHONE NUMBER DENTIST PHONE NUMBER
___________________________________ _______________________________ ____________________________ ______________________________
INSURANCE COMPANY POLICY # GROUP # HOSPITAL PREFERENCE
The most current information has been provided and I understand it is my responsibility to notify the coach and school nurse of any changes. In
addition, I give permission for you to take whatever action you deem necessary for the health and welfare of my child in case of an emergency.
_________________________________________ ___________________ ____________________
PARENT SIGNATURE RELATIONSHIP DATE