HomeMy WebLinkAboutOCDSB 976 Interschool Sport ConsentYour child has expressed interest in joining
and the It runs from to
expected practice schedule, including league games, tournaments and other related activities,
is described below:
OCDSB 976 (June 2020)Page 1
.
Team authorities are expected to exercise reasonable precautions to avoid injury. The
Ontario Physical Education Safety Guidelines designate:
OCDSB 976 Inter-school Sport Consent Form
OCDSB 974: Concussion Code of Conduct (Electronic) - Student OCDSB 974: Concussion Code of Conduct (PDF) - Student OCDSB 975: Concussion Code of Conduct (Electronic) - Parent/Guardian OCDSB 975: Concussion Code of Conduct (PDF) - Parent/Guardian
Participation by students in Inter-school Sports is dependent on the review and submission
of the Concussion Code of Conduct. Students will be prohibited from participating until this
form has been submitted.
Ministry-approved Awareness Resources
Please confirm that you have read one of the following resources.
Ages 10 and Under Ages 11-14 Ages 15 and Up
STUDENT/ATHLETE HEALTH INFORMATION SHEET
Please complete the following health form so that the coaching staff is aware of any
medical issues that might affect your child’s play.
Player’s Name:
Date of Birth:
Home Telephone No.:
Provincial Health
Number (optional):
Parent/Guardian
Name:
Parent/Guardian
Phone No.:
Parent/Guardian
Name:
Parent/Guardian
Phone No.:
Emergency Contact
Name (if parents are not
available):
Telephone No.:
Day/Month/Year
OCDSB 976 (June 2020)Page 2
as a HIGHER/ LOWER risk activity. (Please select one)
Lead Coach/Supervisor:
Names of Coaches/Supervisors:
Please check the appropriate response pertaining to your child and
provide additional details below.
Yes No Previous history of concussions
(Please provide details)
Yes No Hearing problem
Yes
Yes
Yes No Fainting episodes during exercise
Yes No Asthma
Yes No Trouble breathing during exercise Yes
No Heart Condition
No Diabetic
No Has had an illness lasting more
than a week in the past year
Yes
Yes
Yes No Epileptic
Yes No Wears glasses
Yes No Are lenses shatterproof? Yes
No Medication (please provide details)
No Allergies (please provide details)
No Wears a medic alert bracelet or
necklace (please provide details)
Yes No Wears contact lenses Yes No Injuries/illnesses requiring medical
attention in the past year (please
provide details)
Yes No Wears dental appliance (details) Yes No Presently injured (please provide
details)
Yes No Does your child have any other health problems that would interfere with his/her
participation in athletic activities?
Please give details below if you answered “Yes” to any of the above items.
Medications:
Allergies:
Medical Conditions:
Recent Injuries:
Any information not covered above:
Should your son/daughter sustain an injury, concussion or contract an illness requiring
medical attention during the competitive season, please notify the
coach/teacher/supervisor.
OCDSB 976 (June 2020)Page 3
Parent and Student Consent
I understand that it is my responsibility to keep the team management advised of any change in the
above information as soon as possible and that in the event that no one can be contacted, team
management will take my child to the hospital if deemed necessary.
I hereby authorize the physician and nursing staff to undertake the examination, investigation and
necessary treatment of my child.
I also authorize release of information to appropriate people (physicians) as deemed necessary.
I understand that participation on a school team is a privilege and, as such, students are expected to
obey school rules, follow the National Capital Secondary School Athletic Association (NCSSAA) or
Ottawa-Carleton Elementary Athletic Association (OCEAA) Code of Conduct for Athletes, and fulfill their
commitment to their team until the season is over. Failure to do so may result in suspension from school
athletics for the following season.
I have received and read the background information supplied with this request. Permission is given to
the Ottawa-Carleton District School Board for the following student to participate in the activity described
above. If the activity supervisor deems the student’s behavior so disruptive and/or inappropriate as to
warrant cancellation of his/her activity privileges, I agree that he/she will be returned home at my/our (i.e.,
parents’/guardians’) expense.
I give consent for my child to participate in the designated sporting activity.
Date: Signature of Parent/Guardian:
The personal information on this form is collected under the authority of the Education Act (R.S.O. 1990 c.E2), and in accordance
with the Municipal Freedom of Information and Protection of Privacy Act (RSO. 1990 c.M56), as amended. It will be used for
student participation in inter-school sports, and for education-related purposes such as administration, communication, collection
of fees, data reporting, and student transportation services. In addition, the information may be used or disclosed to comply with
legislation, for compelling circumstances affecting health and safety, or discipline related to law enforcement matters. It may be
shared with third parties in accordance with established service agreements, or in accordance with any other Act. Questions or
concerns should be directed to the school principal or the District’s Freedom of Information Coordinator,
Ottawa-Carleton District School Board, 133 Greenbank Road, Ottawa, Ontario K2H 6L3, Telephone 613-596-8211.
CONFIDENTIAL WHEN COMPLETED.
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