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Keene Middle School Athletic Participation Form
This form must be submitted prior to athletic participation and filled out by athlete's parent/guardian
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* Indicates required question
Sport
*
Choose
Soccer
Field Hockey
Cross Country
Basketball
Wrestling
Track
Baseball
Softball
Athlete's Name(Last, First)
*
Your answer
Athlete's Grade
*
6th
7th
8th
Gender
*
Male
Female
Required
Home Address
*
Your answer
Parent/Guardian Email Address
*
Your answer
Phone Number where parent can be reached:
*
Home:
Your answer
*
Cell:
Your answer
Emergency Contact in case parent can not be reached
*
Name:
Your answer
*
Phone Number:
Your answer
Family Physician:
*
Name:
Your answer
*
Phone Number:
Your answer
Medical Info:
*
Does your child have any current medical problems, conditions, or issues that we should be aware of? (i.e., kidney injuries, heart condition or disease, diabetes, asthma, or other, please state below):
Your answer
Allergies
*
Does you child have any allergies that require an Epi-pen?
NO
YES
*
Is your child allergic to any medications? If yes, please state them:
Your answer
Does your child wear eye glasses or contacts?
*
YES
NO
Medical Treatment
*
Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examinations and immunizations for the above named student. In the event of serious illness, significant accidental injury, or the need for major surgery, I understand that an attempt will be made by the attending physician to contact me in the quickest way possible. If the physician is not able to communicate with me, the treatment necessary for the best interest of the above student may be given. In the event that an emergency occurs, an effort will be made to contact the parents or guardians as soon as possible. Permission is also granted to the coach/nurse to treat the student prior to admission to the medical facilities.
I agree
Participation Permission
*
This is to certify that my son/daughter has permission to participate in the Keene Middle School interscholastic and/or intramural athletic programs throughout the school year. My signature below indicates that my son/daughter is physically capable of handling the rigors of the school’s athletic activities. If this permission or attestation as to my son’s/daughter’s physical health is to be restricted to a certain sport or to a certain season or if there are limits upon the activity, I understand that I should see Mr. Margaitis at the school. I also understand that the Keene School District does not administer physical examinations or health screenings to determine a student’s preparedness for the activity. If later I wish to revoke this permission or indicate a limitation on the athletic activity, I understand that I should see Mr. Margaitis.
I agree to the terms above
Required
My son/daughter is covered under the following insurance:
*
Name of Insurance Company:
Your answer
*
Policy Number
Your answer
Waiver of Liability
*
Waiver of Liability: A student’s participation in athletics should be a healthy and fulfilling experience. Nevertheless, there is a substantial risk of injury in any sport. As a parent, I understand this risk and agree that I will not hold any school employee or agent liable or otherwise responsible for any injury as may result from his or her participation in the Keene School District’s athletic programs.
I agree to the terms above
Required
Electronic Signature
*
I agree to all terms on this form and that all information is correct
Required
*
Parent/Guardian Name:
Your answer
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