SECTION 8: ATHLETE RE-CERTIFICATION

This form must be completed not earlier than six weeks prior to the first Practice day of the sport(s) in the sports season(s) identified herein by the parent/guardian of any student who is seeking to participate in Practices, Inter-School Practices, Scrimmages, and/or Contests in all subsequent sport seasons in the same school year. The Principal, or the Principal’s designee, of the herein named student’s school must review the SUPPLEMENTAL HEALTH HISTORY. If any SUPPLEMENTAL HEALTH HISTORY questions are either checked yes or circled, the herein named student shall submit a completed Section 9, Re-Certification by Licensed Physician of Medicine or Osteopathic Medicine, to the Principal, or Principal’s designee, of the student’s school.

Parent/ Guardian (if Athlete is a minor under age 18)

Name

Parent/ Guardian (if Athlete is a minor under age 18)

Name

Parent/ Guardian (if Athlete is a minor under age 18)

Name

Parent/ Guardian (if Athlete is a minor under age 18)

Name

Parent/ Guardian Relationship to Athlete

Athlete Name*

First NameLast Name

Athlete Name

First NameLast Name

Athlete Name

First NameLast Name

Athlete Name

First NameLast Name

Athlete Name

First NameLast Name

Athlete Name

First NameLast Name

Athlete Name

First NameLast Name

Athlete Email*

example@example.com

Athlete Email

example@example.com

Athlete Phone Number*

Athlete Phone Number

Athlete Date of Birth*

Athlete Date of Birth

Athlete Address*

Athlete Address

Parent/ Guardian Phone Number*

Parent/ Guardian Phone Number

Parent/ Guardian Email*

example@example.com

Parent/ Guardian Email

example@example.com

Parent/ Guardian Email

example@example.com

List all school sports that Athlete participates in.*

If any SUPPLEMENTAL HEALTH HISTORY questions below are either answered yes, the herein named student shall submit a completed PIAA Section 9, Re-Certification by Licensed Physician of Medicine or Osteopathic Medicine, to the Principal, or Principal’s designee, of the student’s school.

Since completion of the CIPPE, have you sustained a serious illness and/or serious injury that required medical treatment from a licensed physician of medicine or osteopathic medicine? An additional note to item #1. if serious illness or serious injury was marked “Yes”, please provide additional information below.*

YESNO

Since completion of the CIPPE, have you had a concussion (i.e. bell rung, ding, head rush) or traumatic brain injury?*

YESNO

Since completion of the CIPPE, have you experienced dizzy spells, blackouts, and/or unconsciousness?*

YESNO

Since completion of the CIPPE, have you experienced any episodes of unexplained shortness of breath, wheezing, and/or chest pain?*

YESNO

Since completion of the CIPPE, are you taking any NEW prescription medicines or pills?*

YESNO

Do you have any concerns that you would like to discuss with a physician?*

YESNO

Explain yes answers; include injury, type of treatment & the name of the medical professional seen by student.

I hereby certify that to the best of my knowledge all of the information herein is true and complete.

Athlete Signature*

Parent/ Guardian Signature (if athlete is under age 18)

Date*

Date

RADNOR PERMISSION TO TREAT:

In the event of an emergency requiring medical attention, I grant permission to a physician or other hospital personnel designated by the Radnor coaching staff to attend to my son/daughter (or myself if age 18+).

Adult Athlete or Parent/ Guardian (if athlete is under age 18)*

PHUEL Player:

I hereby give my consent to have an athletic trainer, coach, team manager, emergency medical technician, nurse, medical treatment facility, and/or doctor of medicine or dentistry or associated personnel provide the applicant/participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I understand treatment for injury will be based on information provided herein. I hereby authorize emergency transportation of the applicant/participant to a medical treatment facility should an individual listed above consider it to be warranted. I, the undersigned, do hereby release the RADNOR ULTIMATE FRISBEE CLUB, RADNOR HIGH SCHOOL and PHUEL, their boards, employees, teams, officers, coaches, and referees, as well as any organization that holds any tournament that my child may participate in (RELEASED PARTIES) from any claims arising from personal injury, no matter how caused, which may occur to my child during his/her participation in the program, and/or tournaments and games. In addition, I hereby waive any claims, suits, actions, or causes against RELEASED PARTIES for personal injury, no matter how caused, which my child has incurred, may incur or suffer, during his/her participation in games, tournaments, scrimmages and/or practice sessions. I further agree to indemnify and hold forever harmless the RELEASED PARTIES against all losses, including counsel fees and court costs, from any and all claims made against it by any party as a result of my child's actions, negligent or intentional, which may result in injury or loss to another participant, spectator or other person.

Name Adult Athlete or Parent/ Guardian (if athlete is a minor under age 18) *

Signature of Adult Athlete or Parent/ Guardian (if athlete is under age 18)*

Date

USA ULTIMATE
To enable parents or guardians to authorize the provision of emergency treatment for their children who are injured or become ill while under the authority of RADNOR ULTIMATE FRISBEE. This acknowledges that we, the undersigned parent(s) or legal guardian(s) of or adult athlete, named Athlete Name recognize the potentially hazardous nature of the sport of ULTIMATE that an injury might be sustained.

These injuries include but are not limited to PERMANENT DISABILITY, BLINDNESS, PARALYSIS AND DEATH. In the event of such an injury to my child and we (I or my spouse or guardian) cannot be contacted, we give permission to qualified and licensed EMTs, physicians, paramedics, certified athletic trainers, and/or other medical or hospital personnel to render such treatment.

We (I) release USA Ultimate, its employees, its agents, its volunteers and its assigns from any personal injuries caused by or having any relation to this activity. We (I) understand that this release applies to any present or future injuries or illnesses and that it binds my heirs, executors and administrators.

This release form is completed and signed of my own free will and with full knowledge of its significance. I have read and understand all of its terms.

New 3 Name Adult Athlete or Parent/ Guardian (if athlete is under age 18)

Signature (Adult Athlete or Parent/ Guardian if athlete is under age 18)*

Date

Athlete Phone Number

Family Physician (NAME, ADDRESS, AND PHONE NUMBER)*

Family Physician (Name, Address, & Phone Number)

Preferred Hospital*

Athlete's Medical Insurance Carrier & Co. Phone Number*

Athlete's Medical Insurance Carrier

Medical Policy Number, Grp No., & Subscriber Name*

Medical Policy Number & Group Number

Medical Insurance Address

Emergency Contact(s) (Name, Phone Number, Relationship to Athlete)*

Emergency Contact(s) (Name, Phone Number, Relationship to Athlete)

Specific facts concerning athlete's medical history including allergies, medications being taken, chronic illness or other conditions which a physician should be alerted to such as asthma, diabetes, kidney injury, heart condition, etc. Also indicate if your athlete wears contacts/ glasses.*

Specific facts concerning athlete's medical history including allergies, medications being taken, chronic illness or other conditions which a physician should be alerted to

COMPLETE AND SIGN THE APPROPRIATE PADA AUTHORIZATION BELOW FOR EITHER AN ADULT ATHLETE OR AN ATHLETE UNDER THE AGE OF 18.

Parent/ Guardian Signature

Date

Adult Athlete Signature

Date

Drug and Alcohol Use – Radnor High School policies apply (see DRUG ABUSE AND

ALCOHOLIC BEVERAGES section of the RHS Student Handbook) . In addition, the coaches will

reserve the right to extend the player’s suspension beyond the school’s policy or expel students from the team for any infraction under this policy.

Tobacco Use – Tobacco use is illegal for anyone under the age of 18 and is detrimental to health and athletic performance. Use of tobacco products by an RUF player of any age will not be tolerated. The coaches reserve the right to suspend a player from practices and/or games if that player is observed

using these products. In addition, RHS school policies apply (see Possession or use of cigarettes or

tobacco products on school grounds or on school vehicles section of RHS Student Handbook)

Academic Eligibility – Radnor High School policies apply (see ELIGIBILITY FOR ACTIVITIES

AND ATHLETICS section of the RHS Student Handbook

Attendance – Every practice is important. Athletes are expected to attend all practices. If you are going to miss a practice, game or tournament, it’s your responsibility to inform one of your captains and/or coach prior to your absence. Absences may affect a player’s playing time during games/tournaments. During the spring season, attendance will impact the earning of JV/Varsity letters.

Punctuality – Be on time, our field time is limited and precious. Arriving late to practices/games can be disruptive to the team and will interrupt what your coach is working on. Repeated tardiness may affect your letter eligibility during the spring season.

Attitude & Conduct – You are expected to come to practices, games and tournaments with a positive attitude. Any unsportsmanlike conduct at any time will not be tolerated (i.e. foul language, disrespect toward coaches, teammates, other players, vandalism, etc and could be cause for being removed from a game, sat at practice and/or suspended from the team. Players are expected to leave the fields as they were found by removing all trash and belongings.

We have read and understand the player expectations as stated and agree to abide by these expectations during the Ultimate season.

Athlete Signature*

Parent/ Guardian Signature (if Athlete is under age 18)

Date

If you are new to team snap, please fill this out and return it with your forms packet so we can issue you an invitation to join. Once you receive your invite to Team Snap, you may follow the directions on the following page to get connected!

This form must be signed by the parent or guardian of a student who intends to play Ultimate.

Radnor Ultimate Frisbee (RUF) is considered a club at Radnor High School. Although RUF has the endorsement of the school, the school does not provide financial support or transportation for the players. Students are responsible for their own transportation to all team activities including practices, games and all other team events. As a result, carpools often form to transport players to/from team activities.

If your child does not have your permission to ride with other players, other parents, and/or coaches, it is your responsibility to provide transportation for your child and to ensure that your child does not accept rides from others. In addition, if you do not want your child to drive other players, other parents, and/or other coaches, it is your responsibility to let your child know and to ensure that your child does not offer rides to others. The Radnor Ultimate Frisbee Club is not responsible for arranging transportation or for the safety of players traveling to/from team activities.

I understand that it is my responsibility to make sure that my player knows the arrangements I have made for transportation and follows my instructions regarding accepting rides from or giving rides to others. I also understand that the Radnor Ultimate Frisbee Club is not responsible for my player’s transportation or safety while traveling to/from team events.

Adult Athlete or Parent/ Guardian Signature (if athlete is under age 18) *

New 2 Name Adult Athlete or Parent/ Guardian (if athlete under age 18)

SECTION 8: ATHLETE RE-CERTIFICATION

SUPPLEMENTAL HEALTH HISTORY

EMERGENCY MEDICAL TREATMENT AUTHORIZATIONS

RADNOR ULTIMATE FRISBEE CLUB PLAYER EXPECTATIONS

RADNOR ULTIMATE FRISBEE CLUB TRANSPORTATION