Consent For Athletic Participation, Travel And Medical Care printable pdf download

CONSENT FOR ATHLETIC PARTICIPATION, TRAVEL, AND MEDICAL CARE

**Entire page to be completed by parent/legal guardian

Athlete Information

Last Name _____________________________________ First Name _____________________________________ MI _________________

Gender: ( ) Male ( ) Female

Grade _________

Age ______

DOB _____/_____/____

Known Medical Problems _________________________________________________________________________________________________

Allergies ______________________________________________ Medications _____________________________________________________

Name of Athlete’s Physician _________________________________ Phone #(s) ___________________________________________________

Insurance ________________________________________________________________________ Policy # _____________________________

Group # ____________________________________________________ Insurance Phone #’(s) ________________________________________

Emergency Contact Information

Home Address (include city, state, zip) ___________________________________________________ Phone (

) ______________________

Mother’s Name _______________________________________ Cell (

) _____________________ Work (

) _______________________

Father’s Name _______________________________________ Cell (

) _____________________ Work (

) _______________________

Alternate Contact Name ______________________________ Relationship ______________________ Phone (

) ______________________

Legal Parent (Guardian) Consent

I/We hereby give consent for (athlete’s name) ____________________________ to represent (name of school) _____________________________

in athletics, including related travel, realizing that such activity involves potential for injury. I/We acknowledge that even with the best coaching, the

most advanced equipment, and strict observation of the rules, injuries are still possible., On rare occasions these injuries are severe and result

in disability, paralysis, or even death. I/We further grant permission to the school and TSSAA, its physicians, athletic trainers, and/or EMT

to render aid, treatment, medical, or surgical care deemed reasonably necessary to the health and well- being of the student athlete

named above during or resulting from participation in athletics. By execution of this consent, the student athlete named above and his/her

parent/guardian(s) do hereby consent to screening, examination, and testing of the student athlete during the course of the pre-participation

examination by those performing the evaluation, and to the taking of medical history information and the recording of that history and findings and

comments pertaining to the student athlete on the forms attached hereto by those practitioners performing the examination. As parent(s) or legal

guardian(s), I/we remain fully responsible for any legal responsibility which may result from any personal actions taken by the above name

student athlete.

________________________________ __________________________________ ___________________________________ ______________

Signature of Athlete

Signature(s) of Parent(s)/Legal Guardian(s)

Date

Personal Affidavit In Lieu Of School Insurance

All students who participate in any school-sponsored athletic sport must take out school insurance or file with the principal an affidavit form that they

or their insurance company will be responsible for payment in case of injury.

State Of Tennessee / Rutherford County School System

I/We________________________________________________________, make oath in due form of law that I/We am/are the parents/ guardians of

Name of Parent(s)/Guardian(s)

___________________________ who is a student of ___________________________and that I/we hereby join in the application of said applicant:

Name of Student

Name of School

(Check One*)

____ 1. To be personally

____ 2. To have my/our insurance company

Insurance Company ___________________________________________________________ Policy Number _______________________

responsible for payment of any injury sustained at said school while participating in school-sponsored sports.