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The Commonwealth Of Massachusetts

Executive Office of Health and Human Services

††Department Of Public Health

†††††††††††††††††† 250 Washington Street, Boston, Ma 02108-4619

Charles Baker PRE-PARTICIPATION HEAD
Governor INJURY/CONCUSSION REPORTING FORM

FOR EXTRACURRICULAR ACTIVITIES
Karyn Polito
Lietenant Governor

This form should be completed by the student's parent(s) or legal guardian(s). It must be
Judyann Bigby MD submitted to the Athletic Director, or official designated by the school, prior to the start of
Secretary each season a student plans to participate in a extracurricular athletic activity.

John Auerbach
Commissioner





Name of Student: Sex:††
Date of Birth: Grade:††
Home Address: ††††† City:†† †††† Area Code:
Sport(s):
Telephone: † † Email:††

Has student ever experienced a traumatic heads injury (a blow to the head)?† †Yes †No

Has student ever received medical attention for a head injury?† ††Yes †No

If yes, when?Dates (month/year) also please describe circumstances:

Was student diagnosed with a concussion?† †Yes†No

If yes, when?Dates (month/year):

Duration of Symptoms (such as headache, difficulty concentrating, fatigue) for most recent concussion:†

Parental Consent/Release from Liability and Indemnity Agreement

We the undersigned parent or guardian of a minor, do hereby consent to his/her participation in voluntary educational, recreational, or athletic programs and do forever RELEASE, acquit, discharge and covenant to hold harmless the TOWN OF WINTHROP, a municipal corporation or the Commonwealth of Massachusetts, and its successors, departments, officers, employees, servants and agents, of and from all actions, causes of actions, claims, demands, damages, costs, loss of services, expenses and compensation on account of, or in any way growing out of, directly or indirectly, all known and unknown personal injuries or property damage which we/I may now or hereafter have as the parent/guardian of said minor, and also all claims or right of actions for damages which said minor has or hereafter may acquire, either before or after he/she has reached his/her majority, resulting or to result from his/her participation in the Winthrop Public Schools educational programs, Physical Education Department athletic or recreational programs, FURTHERMORE, we/I hereby agree to protect the Town of Winthrop and its successors, departments, officers, employees, servants, and agents against any claim for damages, compensation or otherwise on the part of said minor growing out of or resulting from injury to said minor in connection with his/her participation in the Town of Winthrop's voluntary programs, and to INDEMNIFY, reimburse or make good to the Town of Winthrop or its successors, departments, officers, employees, servants, or agents any loss or damages or costs, including attorneys fees, the Town or its representatives may have to pay if any litigation arises from said minor's intentional, grossly negligent, or reckless acts or omissions while participating in said education or sports programs.
I futher affirm that I have read this Consent and Release Form and that I understand the contents of this Form.† I understand that my child's participation in these programs is voluntary and that my child and I are free to choose not to participate in said programs. By signing this Form I affirm that I have decided to allow my child to participate in the Town or Public Schools educational, athletic, or recreational programs with full knowledge that the Releases will not be liable to anyone for personal injuries and property damage my child and I may suffer in voluntary Town or Public School educational, athletic or recreational programs.

IN CASE OF EMERGENCY CALL:

†††††††††††††††††††††††††††††††††††††††††††

Name: Phone: Relationship:
Name: Phone: Relationship:
Name: Phone: Relationship:
††††††††††††††††††††††

†††††††††††


If available through the Winthrop Public Schools do you wish to subscribe to Student Accident?

Insurance (optional) † † †Yes ††No

For Sports

Physical Exam: I, the undersigned parent or guardian of said minor above, understand that I am required to provide a physical exam prior to said minorís participation in the Winthrop Public Schools Physical Education Departmentís voluntary athletic programs.Proof of this physical exam by a private doctor must be on file with the Athletic Director prior to any participation.Physical exams must be taken and documented yearly.To cover the full school year, it is suggested that physical exams take place during the summer months when no sports are being played.

Parent's Name: Date:
†(Please check the box to act as a parent signature)
Student's Name: Age:
(Please check the box to act as a student signature)

Winthrop Public School District does not discriminate on the basis of race, sex, color, religion, national origin, sexual orientation, disability, or homelessness.

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