To Be Completed by a Parent Or Guardian

Massachusetts Youth Committed to Winning, Inc.

2014-2015 APPLICATION

To be completed by a parent or guardian. Please print clearly and complete all information.

Player Name:
Home Address:
______
Number Street City/ Town State Zip
Cell: / Sex: / Height: / Weight:

EMERGENCY CONTACT INFORMATION

Parent/ Guardian Name: / Relationship:
Home Address:
______
Number Street City/ Town State Zip
Cell Phone / Work Phone: / Email:

If unable to contact parent/ guardian in emergency, please notify:

Emergency Contact 2: / Relationship:
Home Address:
______
Number Street City/ Town State Zip
Cell Phone / Work Phone: / Email:
Emergency Contact 3: / Relationship:
Home Address:
______
Number Street City/ Town State Zip
CellPhone / Work Phone: / Email:

PLEASE PROVIDE TEAM INFORMATION

Please Circle Grade: 3 4 5 6 7 8 9 10 11 12

Preferred Jersey # _____

HEALTH FACT SHEET

INSURANCE INFORMATION

PEDIATRITION/ PCP Name: / Office Ph.:
Office/ Clinic Address:
______
Number Street City/ Town State Zip
Health Insurance Provider: / Policy #:
DENTIST Name: / Office Ph.:
Office/ Clinic Address:
______
Number Street City/ Town State Zip
Dental Insurance Provider: / Policy #:

Please accurately answer the following questions.

In the event that your child must be transported to a hospital for emergency care, do you have a preference of medical facility? If yes, please list your preferred hospital: ______

Inhaler: If your child uses an inhaler, do you give him/her permission to keep the inhaler with him and to use it as needed? Yes □ No □ ______

Epi-Pen: Will you be registering an Epi-Pen for your athlete? Yes □ No □

My Child: is capable of administering the Epi-pen without assistance.

will require assistance of an adult to administer the Epi-pen.

______

Does your child suffer from any allergies or medical conditions? □ No □ Yes If yes, please describe the severity of the reaction and any medication that is required to treat condition.

______

Medication:

My child is on the following medication:

Massachusetts Youth Committed to Winning, Inc.

2014-2015 APPLICATION

MEDICINE

______

MEDICAL CONDITION

______

Amount per Dose

______

# Doses per Day

______

Massachusetts Youth Committed to Winning, Inc.

2014-2015 APPLICATION

______

Massachusetts Youth Committed to Winning, Inc.

2014-2015 APPLICATION

IMMUNIZATION RECORD AND PHYSICAL FORM

This form must be completed by a physician. Note: A standard Physician’s School/Camp Form will be accepted if it contains all of the following information.

IMMUNIZATION RECORD

ATHLETE NAME:______

IMMUNIZATION / REQUIRED DOSE / DATE / DATE / DATE / DATE / DATE
Tetanus/Diphtheria
Toxoids and Pertussis / 4*
Dta/DTP/DT/Td
MMR / 1
Measles / 2**
Polio (OPV or e-IPV) / 3***
Hepatitis B / 3****

* 3 Doses Tetanus/diphtheria (Td) if over 7 years. Booster dose required if in grades 7 -12.

** Given at least 4 weeks after 1st dose for those entering K-12 or college.

***4 Doses required if mixed schedule given – IPV and OPV.

****For children born after 1/92.

TUBERCULOSIS:

TB Screen: No Risk At Risk

TB/PPD applied on _____/_____/_____ Positive Negative

______

PHYSICAL HEALTH

Sex______Age______Height ______Weight ______BP ______Pulse ______Resp______

System / Satisfactory / Unsatisfactory / Describe Abnormality
Skin
Eyes
Ears
Nose, Throat
Neck, Thyroid
Chest, Breast, Lungs
Heart Rate
Heart Rhythm
Liver, Kidneys, Spleen
Hernia
Back, Spine
Joints
Neurological

The patient does □, does not □, have a history of emotional, psychological or psychiatric disturbance.

The patient may participate in all MYCW YOUTH PROGRAM activities : □without restrictions, □ with the following restrictions: ______

________

Health Care Provider/ Physician:

______

Physician Name (Please Print) Date Physician Signature Date

PARENT VOLUNTEER INFORMATION

The MYCW YOUTH PROGRAM encourages parent and family involvement on many different levels. Athletes will be required to participate in various activities scheduled by their coaching staff and program administrators, parents are invited to become involved in supporting roles. If you would like to support the MYCW YOUTH PROGRAM, please check any areas that are of interest and you will be contacted by the Mighty Mission Administrative Staff.

□ ASSIST IN COMMUNITY OUTREACH FOR EVENTS

□ ASSIST IN PUBLISHING ALUMNI BOOK

□ ASSIST IN TEAM FUNDRAISING

□ CARPOOL TO GAMES AND TOURNAMENTS

□ CARPOOL TO PRACTICES

□ CHAPERONE ON OVERNIGHT TRIPS

□ VOLUNTEER AT EVENTS

Athlete Name:______Team:______

Parent/ Guardian Volunteer Name:______

Relationship to Athlete:______

Address:______

STREET CITY STATE ZIP

Telephone: (H)______(C) ______

PARENT / GUARDIAN AUTHORIZATIONS AND RELEASES

Participation Authorization

I, ______(parent/guardian), hereby authorize my child

______to participate in the “MYCW YOUTH PROGRAM”. By participating in said program, I understand that my child will participate in numerous clinics, camps, outings, and tournaments. In order for the team to participate in all activities, it may be necessary to travel via car, train, bus, and/ or airplane. By signing this consent form you are giving your child permission to travel with the Mighty Mission Basketball team and staff in all capacities previously stated. By signing this consent form, I understand the MYCW YOUTH PROGRAM (staff and/or affiliates) will be not be held accountable for any injuries my child may incur.

______

SIGNATURE OF PARENT/ GUARDIAN DATE

ADDITIONAL TERMS

·  I understand that after the application for MYCW YOUTH PROGRAM has been accepted, if the player subsequently fails to attend, withdraws, experiences incomplete attendance for any reason, or is dismissed, no refund, transfer of any deposit or tuition paid will be made. This applies to all programs and teams incorporated within the MYCW YOUTH PROGRAM.

·  I understand that additional fees may be incurred if my athlete participates in tournaments and events that require travel arrangements (i.e., transportation, meals, lodging, entertainment and out of pocket expenses), and that it is my responsibility to assume these additional costs.

·  I authorize MYCW YOUTH PROGRAM to make, have, use, publish, and reproduce photographs, slides, motion pictures, and/or video tapes of my child for its records, fundraising activities and public relations program.

·  I authorize MYCW YOUTH PROGRAM to release my child’s name, address, and phone number to other MYCW YOUTH PROGRAM families and participants.

·  I have completely and honestly disclosed my child’s Health History and have provided a record of immunization and physical health signed by a physician that can attest to my child’s ability to participate in the MYCW YOUTH PROGRAM.

·  I understand that educational enrichment is part of the MYCW YOUTH PROGRAM and agree to provide a schedule of my child’s school classes, and I further authorize the academic instructors within the MYCW YOUTH PROGRAM to contact my child’s school teachers, and guidance counselor in order to appropriately assess and assist my child in continued academic success.

·  If a situation arises in which my child is in need of prompt medical attention and I, or my designee (emergency contact) cannot be contacted, I hereby grant permission to an authorized member of the MYCW YOUTH PROGRAM staff to authorize treatment for my child. Further, I hereby give my permission to the physician selected by the MYCW YOUTH PROGRAM staff to order X-ray, routine tests and treatment for the health of my child in the event I cannot be reached in an emergency. I hereby give my permission to the physician selected by the MYCW YOUTH PROGRAM staff to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my child as named herein.

·  I understand that the MYCW YOUTH PRGRAM Administrative Staff reserves the right to dismiss an athlete when in his/her judgment, that athlete’s behavior interferes with the rights of others, the smooth functioning of a group or activity, and/or violates the standard of conduct established by the MYCW YOUTH PROGRAM ADMINISTRATIVE STAFF.

·  I have read, I understand and I accept the MYCW YOUTH PROGRAM price schedule and registration policies.

______ ______

SIGNATURE OF PARENT/ GUARDIAN DATE