OCDSB 976: INTER-SCHOOL SPORT CONSENT FORM

Participation by students in Inter-School Sports is dependent on the review and submission of the Concussion Code of
Conduct. Students will be prohibited from participating until this form has been submitted.

OCDSB 974: Concussion Code of Conduct - Student

Please complete this consent form so that the coaching staff is aware of any medical issues that might affect your child's
play.

Activity Information

School School Year

Longfields-Davidson Heights Secondary School 2022-2023

Activity Activity Risk

Jr Boys Soccer Team Higher

Lead Coach/Supervisor
Joel Graham

Other Coaches\Supervisors
Sean Landry, Matt Brown

The expected practice schedule, including league games, tournaments, and other related activities:
Practices in mornings and after schools posted at ldhathletics.ca
Games after school 4 pm posted at fatdog.ca

Team authorities are expected to exercise reasonable precautions to avoid injury. The Ontario Physical Education
Safety Guidelines designate:
https://safety.ophea.net/secondary/interschool/soccer

Student Information

Student First Name * Student Middle Name Student Last Name *

Easton Matthew Eng

Grade *
10

Date of Birth:
Month * Day * Year *

May 8 2007

Parent/Guardian Consent
Should your child sustain an injury, concussion or contract an illness requiring medical attention
during the competitive season, please notify the coach/teacher/supervisor.
Parent and Student Consent

I understand that it is my responsibility to keep the team management advised of any change in the above information as
soon as possible and that in the event that no one can be contacted, team management will take my child to the hospital if
deemed necessary. I hereby authorize the physician and nursing staff to undertake the examination, investigation and
necessary treatment of my child. I also authorize release of information to appropriate people (physicians) as deemed
necessary.

I understand that participation on a school team is a privilege and, as such, students are expected to obey school rules,
follow the National Capital Secondary School Athletic Association (NCSSAA) or Ottawa-Carleton Elementary Athletic
Association (OCEAA) Code of Conduct for Athletes, and fulfill their commitment to their team until the season is over.
Failure to do so may result in suspension from school athletics for the following season.

I have received and read the background information supplied with this request. Permission is given to the Ottawa-
Carleton District School Board for the following student to participate in the activity described above. If the activity
supervisor deems the student’s behavior so disruptive and/or inappropriate as to warrant cancellation of my child's activity
privileges, I agree that my child will be returned home at my/our (i.e., parents’/guardians’) expense.

Video Recordings

The National Capital Athletic Association (NCSSAA) and/or the school may videotape athletic events, including team
practices and/or games. Recordings may be used, in full or in part, for team training and educational purposes, and
recordings of team games may be posted to school or NCSSAA websites/social media platforms.

Consent to Participate *
I give consent for my child to participate in the designated sporting activity.
I DO NOT give consent for my child to participate in the designated sporting activity.

Parent/Guardian First Name * Parent/Guardian Last Name *

Norman Eng

Date
2022-09-25

If you haven't already completed a Concussion Code of Conduct - Parent/Guardian for interschool sports, please click on
the form link below.

OCDSB 975: Concussion Code of Conduct - Parent/Guardian

Parent/Guardian Code of Conduct Acknowledgment *

Participation by students in Interschool Sports is dependent on the review and submission of the Parent/Guardian Code of Conduct form. Students will be
prohibited from participating until this form has been submitted.

I have completed and submitted a parent/guardian code of conduct.

Student Health Information

Provincial Health Number

(optional)

Parent/Guardian Contact Information

Name * Phone Number * Email

1. Norman 613-415-3536 nakae282@gmail.com

(613) 123-4567

Emergency Contact
 Name * Phone Number * Email

Angela Ong 613-415-3950 naka_eng@hotmail.com

(613) 123-4567

Medical Information
* Notes
Previous history of concussions
Yes No
Fainting episodes during exercise
Yes No
Asthma
Yes No
Trouble breathing during exercise
Yes No
Epileptic
Yes No
Wears glasses
Yes No
Shatterproof glasses lenses
Yes No
Wears contact lenses
Yes No
Wears dental appliance
Yes No Braces
Hearing problem
Yes No
Heart condition
Yes No
Diabetic
Yes No
Has had an illness lasting more than a
week in the past year Yes No
Medication
Yes No
Allergies
Yes No Seasonal
Wears a medic alert bracelet or
necklace Yes No
Injuries/illnesses requiring medical
attention in the past year Yes No
Presently injured
Yes No
Any other health problems that could
interfere with their participation in Yes No
athletic activities?

Any other information not covered above:

Personal information on this form is collected under the authority of sections 58.5(1) and 265(d) of the Education Act,
R.S.O. 1990, c.E2, as amended, and in accordance with section 29(2) of the Municipal Freedom of Information and
Protection of Privacy Act. It will be used for the purpose of managing student learning and well-being. Questions about this
collection should be directed to the school principal.