Medical Form

Medical Information/Release Form

In the event of a medical emergency please provide the following information:
Athletes Sport Program
Athlete Information
Athlete's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Grade*
Gender

MaleFemale
Parent/Guardian Emergency Contact Information
Parent/Guardian 1*

First NameLast Name
Relationship*
Phone Number*
Email
example@example.com
Parent/Guardian 2

First NameLast Name
Relationship
Phone Number
Email
Primary Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does your Athlete have any Medication or Other Allergies?*

YesNo
Please List Allergies below:*
Ex: Medications, Bee Stings, Peanuts, Shellfish
Check all that apply to your Athlete*

AsthmaAllergic Reactions (Epi Pen Prescribed)*Breathing ProblemsSickle Cell AnemiaDiabetesHeart ProblemsHearing ProblemsHerniaKidney ProblemsVision ProblemsOther Conditions Not ListedNo Medical Conditions
Please tell us what Allergen your Athlete is prescribed an Epi Pen for:*
Please Tell Us what other Medical Conditions your Athlete has:*
Is the Athlete prescribed an inhaler? If yes, please explain any instructions.*
Is your Athlete currently taking any Medications or Supplements?*

YesNo
Please List all Current Medications/Supplements your Athlete takes:*
SAHSSA COVID-19 Adherense Guidlines

If you or your child are sick stay home until symptoms resolve or otherwise you have a negative COVID-19 test result. Notify your Team Manager as soon as possible.

If you or your child test positive for COVID-19, even if no symptoms develop, isolate for at least 5 days. Day 0 is the day of your positive viral test (based on the date you were tested) and day 1 is the first full day after the specimen was collected for your positive test. You can leave isolation after 5 full days. If you continue to have no symptoms, you can end isolation after at least 5 days. Notify your Team Manager as soon as possible.

If you or your child have had contact with someone who has tested positive for COVID-19 stay home and quarantine for at least 5 full days. Day 0 is the day of last close contact with the person who had COVID-19. Notify your Team Manager as soon as possible.
Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by SAHSSA during the selected Game/Trip. In exchange for the acceptance of said child’s candidacy by SAHSSA, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve, and hold harmless SAHSSA and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected games or trips. In the event of injury to said child, I hereby waive all claims against SAHSSA, including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball, baseball, volleyball, track, and football. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death. Students should be homeschooled or attend school online, not be connected to a public school. Students of Potter's Hand are also eligible.
Medical Release and Authorization As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to the San Angelo Home School Sports Association (SAHSSA) and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature*

Clear
Date*

MonthDayYear
Should be Empty:

Medical Information/Release Form

Parent/Guardian Emergency Contact Information