Florence Sawyer Athletics Registration
NRSD Middle School Athletics Participation Permission Form
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Student First Name *
Student Last Name *
Grade *
Required
Winter Sport *
Parent/Guardian Name *
Address *
(Street, Town)
Parent/Guardian Home Phone Number *
Parent/Guardian Cell Phone Number *
Parent/Guardian Work Phone Number
Parent/Guardian Email Address *
Second Parent/Guardian Email Address *
Emergency Contact #1 *
(Name)
Emergency Contact #1 Phone Number *
(Phone Number)
Emergency Contact #2 *
(Name)
Emergency Contact #2 Phone Number *
(Phone Number)
MEDICAL QUESTIONS
Parents are responsible for completing and filing an NRHS Student Emergency and Health Record annually, an online Athlete Participation Registration Form each season, and, if their child has a medical condition, providing medication orders and a health care plan to the middle school nurse.  Parents are also responsible for ensuring that their child brings/carries his/her emergency medications to all athletic events (practices, matches, games, meets).

Please Note: Carrying an epi-pen or inhaler requires physician permission on file with the school nurse. Epi-pen or inhaler must be provided by parent(s) to coach for sports use.
Does your child have a life-threatening allergy? *
If yes, to what?
Life-threatening allergy
Does your child carry his/her own epi-pen? *
Does your child have asthma? *
Does your child carry his/her own asthma inhaler? *
STATE LAW REGARDING SPORTS-RELATED HEAD INJURY & CONCUSSIONS
The Commonwealth of Massachusetts Executive Office of Health and Human Services now requires that all schools subject to the Massachusetts Interscholastic Athletic Association (MIAA) and Middle Level Athletic Committee (MLAC) rules adhere to the following law. Student-athletes and their parents, coaches, athletic directors, school nurses, and physicians must learn about the consequences of head injuries and concussions through training programs and written materials. The law requires that athletes and their parents inform their coaches about prior head injuries at the beginning of the season. If a student-athlete becomes unconscious, or suspected of having a concussion, during a game or practice, the law now mandates taking the student out of play or practice, and requires written certification from a licensed medical professional for “return to play.”

I confirm that we (student-athlete and parent/guardian) have received the information on concussions that can be found on the following websites:

NFHS Concussion in Sports - What You Need To Know: http://www.nfhslearn.com 

Centers of Disease Control and Prevention at www.cdc.gov/Concussion 

Additional information about concussions can be found on the NRHS Athletics web site http://nrhs.nrsd.net/athletics/participation_requirements/
*
Required
PRE-PARTICIPATION HEAD INJURY/CONCUSSION REPORTING FORM  FOR ATHLETICS & EXTRACURRICULAR ACTIVITIES
Has student ever experienced a traumatic head injury (a blow to the head)? *
If yes, when? Dates (month/year):
Has student ever received medical attention for a head injury?   *
If yes, when? Dates (month/year):
If yes, please describe the circumstances:
Was student diagnosed with a concussion?     *
If yes, when? Dates (month/year):
Duration of Symptoms (such as headache, difficulty concentrating, fatigue) for most recent concussion:
STATE LAW REGARDING SUBSTANCE USE DISORDER
Information on Substance Use Disorder: The Massachusetts Department of Public Health is committed to helping parents keep their children healthy. Based on new Mass State Law, the DPH has regulated that all parents and student-athletes be educated regarding substance use disorder annually. The links below provide information on substance-abuse education.

I confirm that we (student-athlete and parent/guardian) have received the information on substance-abuse that can be found on the following websites:

Information on Substance Use Disorder - http://www.mass.gov/eohhs/gov/departments/dph/programs/community-health/dvip/injury-prevention/substance-use-disorder.html

MA Substance Abuse and Information - http://helpline-online.com/
*
Required
PHYSICAL EXAM UPDATE
Physical Examinations – Submit a valid physical to the middle school nurses’ office.  Physicals are valid for 13 months to the day of the exam – students with expired physicals will be ineligible to participate until a current physical is submitted.
USER FEE AGREEMENT
The Nashoba Regional School Committee has authorized each school to collect an athletic fee from each student-athlete participating in interscholastic sports. The fee for the 2019-2020 academic year is $55.00 per participant per season. Any parent or guardian having difficulties paying a user fee should contact the principal or assistant principal.

Please pay through the district ONLINE PAYMENT SYSTEM at http://www.nrsd.net/families/online_payment_center

Or make checks payable to Florence Sawyer School

Winter user fees are due by December 13, 2019
STUDENT-ATHLETE AGREEMENT
By my signature, this is to certify that I have read and understand the Athletic Handbook for Student-Athletes and Parents and agree to support all MIAA, MSSAA, school, team and athletic regulations. At the conclusion of the season, I agree to return all school-issued equipment or pay the replacement cost for lost equipment or uniforms.
PARENTAL CONSENT, RELEASE FROM LIABILITY AND INDEMNITY AGREEMENT
Minor; do hereby consent to my child’s participation in the above-named voluntary athletic program of the Nashoba Regional School District. I also agree to forever release the Nashoba Regional School District, the School Committee, and all their employees, agents, board members, volunteers and any and all individuals and organizations assisting or participating in the voluntary athletic programs of the Nashoba Regional School District from any and all claims, rights of action and causes of action that may have arisen in the past, or may arise in the future, directly or indirectly, from personal injuries to my child or property damage resulting from my child’s participation in the Nashoba Regional School District voluntary athletic programs.
   I also promise, to indemnify, defend, and hold harmless the Releasees against any and all legal claims and proceedings of any description that may have been asserted in the past, or may be asserted in the future, directly or indirectly, arising from personal injuries to my child or property damage resulting from my child’s participation the Releasees in the Nashoba Regional School District’s voluntary athletic programs.
   I further affirm that I have read 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 Nashoba Regional School District’s athletic programs with full knowledge that the Releasees will not be liable to anyone for personal injuries and property damage my child or I may suffer in voluntary Nashoba Regional School District athletic programs.
   By my signature, this is to certify that I have read and understand the Athletic Handbook for Student-Athletes and Parents and agree to support all MIAA, MSSAA, school, team and athletic regulations enforced by the Nashoba Regional Athletic Department and Administration.
   I understand that the Athletic User Fee described above is non-refundable once my son / daughter are placed on the roster of an athletic team. The fee does not guarantee that the student-athlete will play in each contest. A student-athlete who does not make payment by the due date may not participate in practices or tryouts until the fee is paid.
   I authorize the Athletic Director, Athletic Trainer or Coach to act for me according to their best judgment in an emergency requiring medical attention when they are unable to reach me.

*
Required
Type your name to agree with above statements. *
Signatory must be older than 18 years
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