Athletic Permission to Play Form

WINTER 2019 ATHLETIC PERMISSION TO PLAY FORM

SPORT TO BE PLAYED IN THE WINTER 2019

Student's First Name*

Student's Last Name*

Grade*
Address, City and Zip Code*
Age*
Date of Birth* (mm/dd/yyyy)
Phone*
Today's Date* (mm/dd/yyyy)

Student Signature*



PARENT/GUARDIAN CONSENT

EMERGENCY INFORMATION

PRIMARY EMERGENCY CONTACT
Parent/Guardian*
Home Phone
Cell Phone

SECONDARY EMERGENCY CONTACT
Parent/Guardian*
Home Phone
Cell Phone

THIRD EMERGENCY CONTACT: in the event parents cannot be contacted, please contact:

Name*
Relationship to Student*
Home Phone
Cell Phone

Health Insurance Provider*
Policy#

MEDICAL TREATMENT CONSENT*

I, , the parent/guardian of the above named student, recognize that as a result of athletic participation, medical treatment on an emergency basis may be necessary and further recognize that school personnel may be unable to contact me for my consent for emergency medical care.

Please make the following notations on my son/daughter's records:

Is your child taking any medication?*

Medication(s)

Medication Allergies and Symptoms

Other relevant medical information (e.g. contact lens wearer, history of family diabetes, epilepsy, heart murmurs)

PARENT/GUARDIAN SIGNATURE*
Today's Date (mm/dd/yyyy)

You will now be redirected to the athletic page to complete any additional forms.