Name:
_________________________________________Birth date_________________
Grade: __________
Parent / Guardian:
__________________________________________________________________
Home Phone: _____________________ Work Phone: _________________________
In case of emergency, if you are
unable to reach us please contact:
Name: __________________________
Phone Number: _______________________
Family Doctor:
_______________________ Phone Number: _________
Health Insurance Company:
__________________________________
Policy Number:
______________________
Please indicate your answer by
circling YES or NO for each of the following:
1. The team personnel may administer first
aid until our family doctor can be contacted? YES NO
2.
We give our consent for the team physician, certified
athletic trainer and / or coaches to use their judgment in securing medical aid
and ambulance service if I (we) cannot be contacted immediately.
YES NO
3.
We give our consent for the hospital, their agents
and / or licensed physician to
administer emergency
medical treatment as they deem necessary. YES NO
Our son /
daughter has our permission to practice and compete in
the Huron Valley Schools Interscholastic Athletic Program. We acknowledge the
potential for injury during athletic participation. Although serious injuries are not common in
supervised school athletic programs, it is impossible to eliminate the risk. Participants have the responsibility to help
reduce the chance of injury. Players
must obey all safety rules and report all physical problems to their
coaches.
In
case of accident or injury, we are financially responsible for items such as
ambulance service, doctor’s fees, hospital fees, etc. We have read, understand
and discussed with our son / daughter the regulations and rules of the Huron
Valley Schools Athletic Code of Conduct.
Parent / Guardian Signature:
_____________________________ Date: _________________
Athlete Signature: ______________________________________
Date: _________________