Instrumentalists Club

Consent Form For Immunizations and/or School Physicals Form

In compliance with the requirements of the State of Connecticut and policies regarding immunizations and physical examination for admission to private and public schools, I give my permission/consent for the school physician or a walk-in clinic to complete any and all required immunizations, and/or physical examinations for my daughter
Student's Name*
First Last
1. I am the legal parent/guardian of the below named student at the Academy of the Holy Family High School.
2. I have read the CDC information specific to the immunization requested. For the full legal requirements for school entry visit: https://portal.ct.gov/DPH/Immunizations/Immunization--Laws-and-Regulations If you are unsure if a child is in compliance, please call the Immunization Program at (860) 509-7929.
3. I wish for my daughter to receive the required immunization(s) and/or physical examination to attend the Academy of the Holy Family and agree to pay the appropriate charges.
4. Please note the following contraindications (risk) to immunization: allergy to eggs, latex, thimerosal or other vaccine components, radiation therapy, contact with immune suppressed patients, and pregnancy.
Consent form must be received prior to immunization being administered. Form may also be faxed or emailed. Please keep a copy for yourself.

Student to receive vaccine(s) and/or Physical Examination:
Student's Name*
First Last
Student's Signature*
Today's Date*
MM slash DD slash YYYY
Parent/Guardian's Name*
First Last
Parent/Guardian's Signature*
Today's Date*
MM slash DD slash YYYY
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Tuition Payment

Parent/Guardian Name*
First Last
Phone*
Email*
Student Name*
First Last
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Price*

Enter the amount you would like to pay.
Total
$0.00
Credit Card*
Card Details
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Application

Over-the-Counter Authorization Form

The Connecticut State Law and Regulations requires a physician's written order and parent's/guardian's authorization for a nurse or in her absence, the principal or her designee to administer non-aspirin or aspirin substitutes or over-the-counter medication. IF NEEDED during the current year that this form is filled out.
Name of Student*
First Last
Date of Birth*
MM slash DD slash YYYY
Street/Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Over the counter medication authorization: I hereby give permission for the above named student to use over the counter medications and/or their generic equivalents as directed on the label. It is my understanding that the Academy of the Holy Family has standing medication administration & first aid directives in place signed by their School Physician.
Date(s) medication is to be administered:
From:*
MM slash DD slash YYYY
To:*
MM slash DD slash YYYY
Please list any OTC/Topical medications that your daughter MAY NOT be given.
If none are listed any/all standing ordered OTC medications &/or treatments may be used as appropriate.
Name of Parent/Guardian*
First Last
Email*
Date*
MM slash DD slash YYYY
Signature*
Phone*
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Application

CIAC Student & Parent – Sudden Cardiac Arrest Plan and Consent Form

NOTE: This document was developed to provide student-athletes and parents/guardians with current and relevant information regarding sudden cardiac arrest. A new form is required to be read, signed, dated and kept on file by the student/athlete’s associated school district annually to comply with Connecticut General Statutes Chapter 163, Section 10-149f: SUDDEN CARDIAC ARREST AWARENESS EDUCATION PROGRAM.

PART I – SUDDEN CARDIAC ARREST - What is sudden cardiac arrest?
Sudden cardiac arrest (SCA) is when the heart stops beating, suddenly and unexpectedly. When this happens, blood stops flowing to the brain and other vital organs.
SCA doesn’t just happen to adults; it takes the lives of students, too. However, the causes of sudden cardiac arrest in students and adults can be different. A student’s
SCA will likely result from an inherited condition, while an adult’s SCA may be caused by either inherited or lifestyle issues.
SCA is NOT a heart attack. A heart attack may cause SCA, but they are not the same. A heart attack is caused by a blockage that stops the flow of blood to the heart.
SCA is a malfunction in the heart’s electrical system, causing the heart to suddenly stop beating.

PART II - HOW COMMON IS SUDDEN CARDIAC ARREST IN THE UNITED STATES?
SCA is the #1 cause of death for adults in this country. There are about 300,000 cardiac arrests outside hospitals each year. It is a leading cause of death for student-athletes. According to an April 2014 study for PubMed the incidence was:
•0.63 per 100,000 in all students (6 in one million)
•1.14 per 100,000 athletes (10 in one million)
•0.31 per student non-athletes (3 in one million)
•The relative risk of SCA in student-athletes vs non-athletes was 0.65
•There is a significantly higher risk of SCA for boys than girls
Leading causes of sudden death among high school and college athletes, according to the National Collegiate Athletic Association (NCAA) (on CBS News, June 28, 2012)* are heat stroke, heart disease and traits associated with sickle cell anemia. Prevention of sudden death, the same study concludes, is associated with more advanced cardiac screening with attention to medical histories and birth records, improved emergency procedures, and good coaching and conditioning practices. SCA can be prevented if the underlying causes can be diagnosed and treated.

PART III - WHAT ARE THE WARNING SIGNS AND SYMPTOMS?
Although SCA happens unexpectedly, some people may have signs or symptoms, such as: fainting or seizures during exercise; unexplained shortness of breath; dizziness; extreme fatigue; chest pains; or racing heart.
These symptoms can be unclear in athletes, since people often confuse these warning signs with physical exhaustion.

Sudden cardiac arrest is a medical emergency. If not treated immediately, it causes sudden cardiac death. With fast, appropriate medical care, survival is possible. Administering cardiopulmonary resuscitation (CPR) – or even just compressions to the chest – can improve the chances of survival until emergency personnel arrive. (http://www.mayoclinic.org/diseases-conditions/sudden-cardiac-arrest/basics/)

WHAT ARE THE RISKS OF PRACTICING OR PLAYING AFTER EXPERIENCING THESE SYMPTOMS?
There are risks associated with continuing to practice or play after experiencing these symptoms. When the heart stops, so does the blood that flows to the brain and other vital organs. Death or permanent brain damage can occur in just a few minutes. Most people who experience SCA die from it.

REMOVAL FROM PLAY
Any student-athlete who shows signs or symptoms of SCA must be removed from athletic activity and referred to a licensed health care profession trained specifically in the treatment of cardiac care. The symptoms can happen before, during or after activity.

RETURN TO PLAY
Before returning to play, the athlete must be evaluated. Clearance to return to play must be in writing. The evaluation must be performed and written clearance be provided by a licensed medical provider.

To summarize:
•SCA is, by definition, sudden and unexpected.
•SCA can happen in individuals who appear healthy and have no known heart disease.
•Most people who have SCA die from it, usually within minutes.
•Rapid treatment of SCA with a defibrillator can be lifesaving.
•Training in recognition of signs of cardiac arrest and SCA, and the availability of AED’s and personnel who possess the skills to use one, may save the life of someone who has had an SCA.

(National Heart, Lung, and Blood Institute)

I have read and understand this document the “Student & Parent Informed Consent Form” and understand the severities associated with sudden cardiac arrest and the need for immediate treatment of any suspected condition.
Student Name*
First Last
Date*
MM slash DD slash YYYY
Signature*
I authorize my child to participate in*

(Sport/Activity)
For school year*
Parent/Guardian Name*
First Last
Parent/Guardian Email*
Signature*
Date*
MM slash DD slash YYYY
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CIAC (Connecticut Interscholastic Athletic Conference) Student and Parent Concussion Information Consent Form

This consent form was developed to provide students and parents with current and relevant information regarding concussions and to comply with Connecticut General Statutes (C.G.S.) Chapter 163, Section 149b: Concussions: Training courses for coaches. Education plan. Informed consent form. Development or approval by the State Board of Education and Section 10-149c: Student athletes and concussions. Removal from athletic activities. Notification of parent or legal guardian. Revocation of coaching permit. What is a Concussion?
National Athletic Trainers Association (NATA) - A concussion is a “trauma induced alteration in mental status that may or may not involve loss of consciousness.”

Centers for Disease Control and Prevention (CDC) - “A concussion is a type of traumatic brain injury, or TBI, caused by a bump, blow, or jolt to the head that can change the way your brain normally works. Concussions can also occur from a blow to the body that causes the head to move rapidly back and forth.” -CDC, Heads Up: Concussion http://www.cdc.gov/headsup/basics/concussion_whatis.html

Even a “ding,” “getting your bell rung,” or what seems to be mild bump or blow to the head can be serious” -CDC, Heads Up: Concussion Fact Sheet for Coaches https://www.cdc.gov/headsup/pdfs/custom/headsupconcussion_fact_sheet_coaches.pdf
Section 1. Concussion Education Plan Summary
The Concussion Education Plan and Guidelines for Connecticut Schools was approved by the Connecticut State Board of Education in January 2015. Below is an outline of the requirements of the Plan. The complete document is accessible on the CSDE Web site: http://www.sde.ct.gov/sde/cwp/view.asp?a=2663&q=335572

State law requires that each local and regional board of education must approve and then implement a concussion education plan by using written materials, online training or videos, or in-person training that addresses, at a minimum the following:
1. The recognition of signs or symptoms of concussion.
2. The means of obtaining proper medical treatment for a person suspected of sustaining a concussion.
3. The nature and risks of concussions, including the danger of continuing to engage in athletic activity after sustaining a concussion.
4. The proper procedures for allowing a student athlete who has sustained a concussion to return to athletic activity.
5. Current best practices in the prevention and treatment of a concussion.
Section 2. Signs and Symptoms of a Concussion: Overview
A concussion should be suspected if any one or more of the following signs or symptoms are present, or if the coach/evaluator is unsure, following an impact or suspected impact as described in the CDC definition above.

Signs of a concussion may include (i.e. what the athlete displays/looks like to an observer):
• Confusion/disorientation/irritability
• Trouble resting/getting comfortable
• Lack of concentration
• Slow response/drowsiness
• Incoherent/ slurred speech
• Slow/clumsy movements
• Loses consciousness
• Amnesia/memory problems
• Acts silly/combative/aggressive
• Repeatedly ask same questions
• Dazed appearance
• Restless/irritable
• Constant attempts to return to play
• Constant motion
• Disproportionate/inappropriate reactions
• Balance problems

Symptoms of a concussion may include (i.e. what the athlete reports):
• Headache or dizziness
• Nausea or vomiting
• Blurred or double vision
• Oversensitivity to sound/light/touch
• Ringing in ears
• Feeling foggy or groggy

State law requires that a coach MUST immediately remove a student-athlete from participating in any intramural or interscholastic athletic activity who: a) is observed to exhibit signs, symptoms or behaviors consistent with a concussion following a suspected blow to the head or body, or b) is diagnosed with a concussion, regardless of when such concussion or head injury may have occurred. Upon removal of the athlete, a qualified school employee must notify the parent or legal guardian within 24 hours that the student athlete has exhibited signs and symptoms of a concussion.
Section 3. Return to Play (RTP) Protocol Overview
Currently, it is impossible to accurately predict how long an individual’s concussion will last. There must be full recovery before a student-athlete is allowed to resume participating in athletic activity. Connecticut law now requires that no athlete may resume participation until they have received written medical clearance from a licensed health care professional (physician, physician assistant, advanced practice registered nurse (APRN), athletic trainer) trained in the evaluation and management of concussions.

Concussion Management Requirements: 1. No athlete SHALL return to participation in the athletic activity on the same day of concussion.
2. If there is any loss of consciousness, vomiting or seizures, the athlete MUST be immediately transported to the hospital.
3. Close observation of an athlete MUST continue following a concussion. The athlete should be monitored for an appropriate amount of time following the injury to ensure that there is no worsening/escalation of symptoms.
4. Any athlete with signs or symptoms related to a concussion MUST be evaluated by a licensed health care professional (physician, physician assistant, advanced practice registered nurse (APRN), athletic trainer) trained in the evaluation and management of concussions.
5. The athlete MUST obtain an initial written clearance from one of the licensed health care professionals identified above directing her/him into a well-defined RTP stepped protocol similar to the one outlined below. If at any time signs or symptoms return during the RTP progression, the athlete should cease activity*.
6. After the RTP protocol has been successfully administered (no longer exhibits any signs or symptoms or behaviors consistent with concussions), final written medical clearance is required by one of the licensed health care professionals identified above for the athlete to fully return to unrestricted participation in practices and competitions.
I have read and understand this document the “Student and Parent Concussion Informed Consent Form” and understand the severities associated with concussions and the need for immediate treatment of such injuries.
Student Name*
First Last
Date*
MM slash DD slash YYYY
Signature*
I authorize my child to participate in*

(Sport/Activity)
For school year*
Parent/Guardian Name*
First Last
Parent/Guardian Email*
Signature*
Date*
MM slash DD slash YYYY
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Emergency Contact Information/Consent Form

Student Information
Student's Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Grade*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Cell Phone*
Student Email Address*
Allergies
Medications
Parent /Guardian Information-– First Contact
Name*
First Last
Relationship*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

(if different from above)
Home Phone*
Cell Phone*
Work Phone
Email*
Emergency Contact #1
(In case parents/guardians cannot be reached and are authorized to pick up your child)
Name*
First Last
Relationship*
Home Phone*
Cell Phone*
Work Phone*
Emergency Contact #2
(In case parents/guardians cannot be reached and are authorized to pick up your child)
Name*
First Last
Relationship*
Home Phone*
Cell Phone*
Work Phone*
Are you an International Student?*
- Yes
- No
International Student
Please provide the contact information of an English-speaking individual residing in the United States.
Name*
First Last
Relationship*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Cell Phone*
Work Phone
In the event of an illness or accident, I hereby authorize Academy of the Holy Family High School to act on my behalf for the student named above in the securing of medical, surgical, psychological and/or dental treatment. In the event of an emergency, I hereby give my permission to the health care provider selected by Academy of the Holy Family High School to hospitalize, secure proper treatment for, and to order injections, anesthesia, or surgery for the student named above. If such an event occurs, I understand that every effort will be made to contact me as soon as possible. I certify that I am the parent/guardian or have the legal ability to sign these authorizations on behalf of the student named above. I understand I am responsible for all expenses that the above named students insurance does not pay.
Parent/Guardian Initial Here*
Date*
MM slash DD slash YYYY
I give Academy of the Holy Family Health Office permission to obtain/provide/exchange information with any health care provider or health care facility. This includes but is not limited to hospitals, walk-in centers, emergency care centers and individual physicians that my daughter may be sent to for medical or psychological evaluation and treatment. This exchange of information includes staff responsible for the health and well-being of student. I understand that I may withdraw my consent at anytime by providing a written request limiting the exchange of information. The Family Right to Privacy Act will protect information placed in my daughter’s school health record.
Parent/Guardian Name*
First Last
Relationship*
Parent/Guardian Signature*
Date*
MM slash DD slash YYYY
Medical Card for Coach
This form will accompany the athlete to the doctor or hospital if medical attention is required.
Name of Medical/Accident Insurance Company*
Phone*
Policy Holder Name*
First Last
Policy Holder SS#*
Policy Holder Date Of Birth*
MM slash DD slash YYYY
Address of Policy Holder*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Policy No.*
Group No.*
In the event I cannot be reached, I hereby authorize and grant to the staff of Academy of the Holy Family School permission to administer or obtain medical care, perform any necessary treatments, and/or administer medication to my daughter. When necessary, I give my permission for the staff at Academy of the Holy Family to seek and obtain medical treatment for my daughter on an emergency or as needed basis at a licensed hospital, clinic and/or a licensed physician, nurse practitioner or physician’s assistant.
Parent/Guardian Signature*
Date*
MM slash DD slash YYYY
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