You will have to fill out the 2 pages below: Athletic and Sporting Events Waiver and Medical emergency form. I have cut and pasted them below, or you can go directly to the diocesan website for them http://www.cdop.org/pages/EdSchoolsFormsGen.aspx If you have already filled one out, make a copy of it for us (we have to take it with us when we go on trips) Athletic and Sporting Events Parental/Guardian Consent Form and Liability Waiver 2009-2010 Academic Year Student Participant’s Name: ____________________________________________________________________________ Birth Date: ________________________________________ Sex: ___________________________________________ Parent/Guardian’s Name: ______________________________________________________________________________ Home Address: ________________________________________________________________________________________ Home Phone: _______________________ Business: _______________________ Cell: _______________________ Request for Permission As parent and/or legal guardian, I give permission for my son/daughter named above to participate in interscholastic athletics in the following sports during the 2009-2010 academic year (initial all that apply): _____ Baseball _____ Football _____ Tennis _____ Basketball _____ Golf _____ Track & Field _____ Cheerleading _____ Soccer _____ Volleyball _____ Cross Country _____ Softball _____ Wrestling _____ Dance Team _____ Swimming _____ Other: ______________________ As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor (“participant”). I am aware that participating in sports will involve travel to practices and games. I acknowledge and accept the risks involved with my child’s travel. I further understand that participation in sports presents to my child the risk of harm, including, but not limited to, serious personal injury or death. Any questions I have concerning my child’s participation have been answered. In consideration of my child being allowed to participate in the sport(s) indicated above, I hereby RELEASE AND AGREE TO INDEMNIFY AND HOLD HARMLESS the Catholic Diocese of Peoria, the parish, the school, coaches, chaperones, volunteers or representatives associated with the event, and their employees and agents, from any and all liability for injuries, damages, medical expenses, or any other loss to my child or family or me (including attorneys’ fees) arising from or related to my child’s participation. Additionally, I give my consent and approval for my child’s name and picture to be printed in any sports program, publication, or video. As a parent/guardian, I further acknowledge that I am a role model. I will remember that school athletics is an extension of the classroom, offering important learning experiences for the students. Therefore, I will show respect for all players, coaches, spectators, and officials. I will only participate in cheers that support, encourage, and uplift the teams involved. I understand the spirit of fair play and good sportsmanship expected by a Catholic school, and accept the responsibility that comes with being a parent/guardian of a student athlete. Signature: ___________________________________________ Date: ________________________________________ MEDICAL INFORMATION & EMERGENCY FORM Please note: schools may use this form or a commercially available medical information / emergency form template. Student/Minor: Name (first, middle, last): ________________________________________________________________ Address: ___________________________________________________________________________ Student/Minor’s Regular Physician: Name (first, middle, last): ______________________ Phone (including area code): _____________________ Medical Conditions: Please list any medical conditions of the student/minor (asthma, diabetes, epilepsy, etc.): ______________________ __________________________________________________________________________________ List any allergies or allergic reactions to medications of the student/minor: _______________________________ __________________________________________________________________________________ List any medications the student/minor is presently taking: __________________________________________ __________________________________________________________________________________ Other pertinent medical information: ________________________________________________________ __________________________________________________________________________________ Date of student/minor’s most recent tetanus shot: ________________________________________________ Medical Insurance Information: Company: __________________________________________________________________________ Plan Number: __________________________ Employee Identification #: __________________________ Emergency Contacts Parent or Guardian Name (first, middle, last): __________________________________________________________________ Daytime Phone (including area code): ________________________ Evening Phone (including area code): ______________________ Other Contact Name (first, middle, last): _________________________ Phone (including area code): _____________________ Relationship (friend, neighbor, coworker, etc.): _____________________________________________________ Authorization for Emergency Medical Treatment This information will be kept in the possession of the school/parish. A copy will be distributed to the person in charge of each trip or athletic activity in which the student/minor participates. Should the need arise this information will be given to the proper medical authorities. I, ________________________ [parent/guardian], understand that in the case of illness or injury to my child, _____________________[child’s name], the school/parish will try to notify me or the person I have listed above as an emergency contact. In case of medical emergency concerning my child, at a time when I or my listed emergency contact cannot be notified, I grant full power to the school/parish to 1) arrange for the transportation of my child, whether by ambulance or otherwise, to a proper facility where emergency medical treatment would normally be administered, including but not limited to, an emergency room of a hospital, a doctor’s office, or a medical clinic; and 2) sign releases as may be required in order to obtain any medical or surgical treatment as is required in the judgment of medical authorities at the facility. _______________________________________________________________ _____________________________________________________ Signature of Parent/Guardian Date This Authorization for Emergency Medical Treatment is valid for a period of one year, from August ___, 20__ through August ___, 20___. |