MSAD 55 Athletic Participation Consent Form
This form is required prior to a student athlete participating on athletic teams at Sacopee Valley High School and Sacopee Valley Middle School.
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Email *
Student's Name (First and Last) *
Student's Grade (during the sports season) *
Date of Birth *
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/
DD
/
YYYY
Parent/Guardian's Name (First and Last) *
Student's Address (Street/PO, Town, Zip) *
Home Phone
Cell Phone
Alternate Phone
Student Email
Parent Email
INSURANCE INFORMATION
Athletic Insurance Waiver.  I fully understand that MSAD 55 does not provide any accident or health insurance coverage for my son/daughter while participating in interscholastic athletics.  I fully understand that it is my responsibility to provide insurance coverage for my child. *
My child is adequately covered by family health and accident insurance. *
Insurance Company Name and Policy Number. *
PHYSICAL EXAM INFORMATION
I understand that MSAD 55 requires that students must have yearly (up-to-date) physical exam before trying out and participating in interscholastic athletics. *
My child has had a physical exam this school year by our family physician.  If yes, please provide the school with a copy of the examination with authorization to participate in athletics. (school fax:  207-625-7869) *
My child has permission to be examined by the school physician (limited dates available). *
Please provide the date of the last known physical exam below. *
ATHLETIC PARTICIPATION CONSENT
Legal Guardian consent.  I hereby certify that the student named above may take part in the following interscholastic activities during the 2016-2017 school year. *
Required
I understand that this involves practice sessions, participation in any events and transportation to and from such events. I authorize the school to obtain a physician of its' choice for any emergency medical care that may become reasonably necessary for the student in the course of such athletic activities or travel. *
Reporting Consent.  I understand that, at times, my child's name and photo may be used on the internet when reporting information regarding the school athletics or other school activities.  I give permission for my child's name or photo to be used on the internet when reporting school information regarding school athletics or other school activities. *
I have read and understand the MSAD 55 Concussion Policy as well as the steps taken should my child receive a concussion. *
I give my child permission to partake in the  ImPact Concussion Management and testing program. *
Overall Consent.  I hereby give my consent for the student named above: 1.) to represent his/her school in approved athletic activities. 2.) to accompany any school team of which he/she is a member on its local and out of town trips. 3.) to receive, through a medical doctor of the school's choice, emergency care which may become necessary in the course of such athletic activities or associated travel.  4.) I further agree not to hold the school or anyone acting on its behalf responsible for any injury occurring to the named student in the proper course of such athletic activities or travel. *
I have read the above information and will abide by the principles and regulation.  I have also read the EXTRACURRICULAR CODE OF CONDUCT, the ACADEMIC ELIGIBILITY POLICY,  the MSAD 55 CONCUSSION POLICY and information regarding IMPACT Testing as well as other related district policies.  I agree to comply with these rules.  By typing my name and email address below, I acknowledge that we have read and understand all information and that I am the parent or guardian authorized to complete this form.  Parents and students who do not wish to accept the responsibilities should not type there name and email below. (Students Name, Parent/Guardian's Name, Parent/Guardian email address) *
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