D.A. Athletic Registration Form 2022-2023

MUST BE COMPLETED BEFORE TRYOUTS

The Dominic Murray Sudden Cardiac Arrest Prevention Act is a new law as of July 1, 2022. This law requires schools, students, and parents/guardians have information on sudden cardiac arrest risks, signs, and symptoms. Please note that sudden cardiac arrest in children and youth is rare. The incidence of sudden cardiac death (SCD) on the playing field is 0.61 in 100,000.

Sudden Cardiac Arrest (SCA) is an emergency that happens when the heart suddenly stops working. SCA can cause death if not treated immediately, and even with treatment death may occur. Immediate treatment is cardiopulmonary resuscitation (CPR) and use of an automatic external defibrillator (AED).

Preventing SCA before it happens is the best way to save a life. Both your family health history and your child’s personal history must be told to healthcare providers to help them know if your child is at risk for sudden cardiac arrest. Ask your child if they are having any of the symptoms listed below and tell a healthcare provider. Know your family history and tell a healthcare provider of any risk factors listed below.

The signs or symptoms are:

• Fainting or seizure, especially during or right after exercise or with excitement or startled
• Racing heart, palpitations, or irregular heartbeat
• Dizziness, lightheadedness, or extreme fatigue with exercise
• Chest pain or discomfort with exercise
• Excessive shortness of breath during exercise
• Excessive, unexpected fatigue during or after exercise

Student’s Personal Risk Factors are:

• Use of diet pills, performance-enhancing supplements, energy drinks, or drugs such
  as cocaine, inhalants, or “recreational” drugs.
• Elevated blood pressure or cholesterol
• History of health care provider ordered test(s) for heart related issues

Student’s Family History Risk Factors are:

• Family history of known heart abnormalities or sudden death before 50 years of age
• Family members with unexplained fainting, seizures, drowning, near drowning or caraccidents before 50 years of age
• Structural heart abnormality, repaired or unrepaired
• Any relative diagnosed with the following conditions:

▪ Enlarged Heart/ Hypertrophic Cardiomyopathy/Dilated Cardiomyopathy
▪ Arrhythmogenic Right Ventricular Cardiomyopathy
▪ Heart rhythm problems, long or short QT interval
▪ Brugada Syndrome
▪ Catecholaminergic Ventricular Tachycardia
▪ Marfan Syndrome- aortic rupture
▪ Heart attack at 50 years or younger
▪ Pacemaker or implanted cardiac defibrillator (ICD)

SCA in students at risk can be triggered by athletic activities. To decrease any chance of SCA in a student, the Interval Health History for Athletics must be completed and signed by a parent/guardian before each sports season unless a physical examination has been conducted within 30 days before the start of the season. This form has questions to help identify changes since the last physical examination or health history was completed. School personnel may require a student with health or history changes to see a healthcare provider before participating in athletics.

Finally, the law requires any student who has signs and symptoms of pending SCA be removed from athletic activity until seen by a physician. The physician must provide written clearance to the school for the student to be able to return to athletics.

Please contact the State Education Department’s Office of Student Support Services for questions at
studentsupportservices@nysed.gov or 518-486-6090.

Required for all student-athletes. Please see the below Interval Health History form. This form must be completed by a parent/guardian and uploaded no sooner than 30 days prior to the first try-out of each new season. Failure to do so will result in the student-athlete being unable to participate in any athletic activity, including tryouts.

Click link for Child & Adolescent Health Examination Form

I, {parentguardianName}, parent or guardian of, {athletesName}, understand that every effort will be made to reach me in the event of a medical emergency involving my child. If this is not possible, I hereby acknowledge and permit reasonable action to be taken by Dominican Academy, its representative, coaching personnel, or parent volunteer, to secure appropriate medical care, at my expense, for my child in the event of my child’s injury or illness. Such medical care includes emergency medical treatment, hospitalization, or other medical treatment as may be necessary for the welfare of my child, performed by a physician, nurse, emergency medical technician, urgent care center, and/or hospital emergency room. Furthermore, I hereby waive, on behalf of myself and my child, any liability of Dominican Academy, the New York Archdiocese, and its agents, coaches, volunteers, or employees, arising out of such medical treatment. I further certify that I have adequate medical insurance covering my child for any such medical or surgical expenses incurred.

I, {parentguardianName}, do hereby give my child/ward, {athletesName}, permission to participate in the sport of, {planTo}, on a Dominican Academy sports team. I am fully aware that my child’s participation in the subject sport has inherent physical risks, including injuries that can and may occur. On occasions, these injuries can cause temporary or permanent disability, temporary or permanent paralysis, or death, and while particular rules, equipment, and personal discipline may reduce these risks, the risks of serious injury and illness are real and do exist. I agree that medical insurance coverage for my child while participating in the subject sport will be provided by me and/or my spouse.

In consideration of my child being allowed to play, on my child’s behalf, upon my own, and on behalf of my spouse, my/our heirs, relatives, assigns, beneficiaries, executors, administrators, personal representatives, and next of kin, I knowingly and voluntarily assume any and all such risks of illness or personal injury, paralysis, or death, or any other loss, she/ we may sustain, both known and unknown, caused by my child’s participation in the subject sport, including transportation to/from sports events, even if arising from the negligence of the
Released Parties and others.

Furthermore, I, for myself, for my spouse, and for my child and on behalf of my/our heirs, relatives, assigns, beneficiaries, executors, administrators, personal representatives, and next of kin, hereby expressly release, hold harmless, and forever discharge, Dominican Academy, The Archdiocese of New York, and their related entities, officers, administrators, faculty, coaches, volunteers, officials, agents, representatives, employees, other participants, and owners and lessors of premises upon which the activity may take place (the “Released Parties”), from any and all claims, demands, suits, costs, causes of action, losses, and liability of any kind whatsoever, whether in law or equity, arising out of or related to any and all personal injuries or property damage caused by or resulting from my child’s participation in the subject sport, whether arising from the negligence of the Released Parties or otherwise, to the fullest extent permitted by law.

Furthermore, I shall indemnify, defend, and hold harmless, the Released Parties from and against any and all claims, damages and liabilities incident to my child’s involvement or participation in the subject sport, even if arising from the negligence of the Released Parties, to the fullest extent permitted by law.