Sample Intramural Medical Information and Consent to Participate Form
PLEASE NOTE: FREEDOM OF INFORMATION- The information provided on this form is collected pursuant to the Board’s education responsibilities as set out in the Education Act and its regulations. This information is protected under the Freedom of Information and Protection of Privacy Act and will be utilized only for the purposes related to the Board’s Policy on Risk Management. Any questions with respect to this information should be directed to your school principal.
Parents/guardians are requested to complete this Intramural Medical Information and Consent to Participate Form and return it to their child/ward’s teacher.
(Where your child’s/ward’s condition is confidential or requires further explanation you are requested to contact your child’s/ward’s teacher.)
Is your child allergic to any drugs, food or medication/other?
Medic Alert Information
Does your child/ward wear a medical alert bracelet?
Does your child/ward wear a neck chain?
Does your child/ward carry a medical alert card?
Oral and Visual Appliance
Does your child/ward wear eyeglasses?
Does your child/ward wear contact lenses?
Does your child/ward wear orthodontic appliance?
Does your child/ward have dental restorations (that is, crowns, bridges)?
Indicate if your child/ward has been diagnosed as having any of the following medical conditions and provide relevant details:
Does your child/ward take any prescription drugs?
Indicate any physical ailments that apply and provide relevant details:
Has your child/ward previously been diagnosed with a concussion?
If your child/ward is presently diagnosed with a concussion by a medical doctor/nurse practitioner, that was sustained outside of school physical activity, a Medical Concussion Assessment Form must be completed before the student returns to intramural activities/clubs. Request the form from the school administrator.
Elements of Risk Notice
I acknowledge and have read the Elements of Risk notice in the Intramural Parent/Guardian Letter.
Intramural Activities/Clubs Permission
I give permission for my child/ward to participate in intramural activities/clubs.