Athletic Permission to Play Form

    SPRING 2021 ATHLETIC PERMISSION TO PLAY FORM

    SPORT TO BE PLAYED IN THE SPRING 2021

    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.