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Permission Slip


Sport:

First Name:
Last Name:

Street Address:
City:
State:
Zip Code:

Home Phone:

Date of Birth:

Age:

Grade:

To the Parent or Guardian: In order that your son, daughter, or ward may participate in various school athletic activities other than those carried on as part of the regular physical education class program, it will be necessary for you to give your written consent.

Permission is given for son, daughter, or ward to participate in this sport.

It is understood that time after school will be requited for practice and competition. The school will provide proper and reasonable supervision at practice and games and travel to and from such practice and games. Beyond this point of proper supervision, the school cannot assume responsibility for injuries.

A student is financially responsible for the replacement cost of athletic equipment and uniforms which are not returned within ten (10) days after the close of a given season.

In addition, it is recognize that the student must comply with the eligibility regulations governing Perry Hall Christian School athletics as approved by the County Superintendent and legislative committee.

In order to participate in interscholastic activities, the student must have accident insurance coverage in effect. (Please check below)

Student is covered by school insurance (must be purchased from the school office).

Blue Cross/Blue Shield
                                            policy number
Other commercial issurance
                                                   company and policy number

In and emergency, if parents cannot be contacted:

Notify: at (Phone #)

Family Doctor: at (Phone #)

Preferred Hospital:

Known Allergies:

The team physician, trainer, and coach may apply first aid treatment until the family doctor can be contacted.
Yes No

We give our consent for coaches, trainers, and team physicians to use their own judgment in securing medical aid and ambulance service in the case the parents cannot be reached. Yes No

I have read the above statements and hereby give my written consent.

Date: