Consent For Athletic Participation, Travel And Medical Care (Page 2 of 2) in pdf

Consent For Athletic Participation, Travel And Medical Care Page 2

Proof of Residence

According to Rutherford County Board Of Education Policy ADM5-66.5 (Interscholastic

Athletics), it is required that all coaches verify that athletes’ addresses are within the school

attendance zone prior to beginning practice each year.

You must submit this form along with the following documents to be eligible to try out for any

Interscholastic Athletic team:

1. A current utility bill

2. A copy of zone verification from the Rutherford County Schools Website

**To obtain a copy of your verification you should log on to

Click on

School Zone/Bus Route Info. Type in your complete street address and grade. Print the

screen that verifies that you are zoned for ______________________________ ..

Name of School

A copy of a valid zone exemption year to attend ______________________

for the _______________ school year .

Name of School

Student Name__________________________________________________

Address_______________________________________________________

**Must be the primary domicile of the student’s custodial parent/guardian.

Parent/Guardian Name_________________________________________

Phone Number(s) _________________________________________________

I hereby state the above information is correct.

_______________________ _______________________

_____________

Signature of Student

Signature of Parent/Guardian

Date

Consent For Athletic Participation, Travel And Medical Care Page 2