Interscholastic Athletics Parental Consent Form printable pdf download

Public Schools Athletic League

Interscholastic Athletics Parental Consent Form

Students Name: ___________________________

Date of Birth: ____________________

High School: ______________________________

Official Class: ____________________

Sport: ___________________________________

OSIS Number: ___________________

I, the parent/guardian of the student named above, hereby, give permission for my child to try out for the team

indicated, and participate in all of the team’s activities, as directed by the school/coach. I understand that my

child’s participation in this activity is purely voluntary. However, if selected, I understand that my child will be

required to attend regularly scheduled practices and competitions throughout the City of New York. Initial____

I understand that my child will meet all PSAL practice and participation requirements. Initial____

I understand that my child is responsible for his/her behavior at all time, and agree not to hold the school or any

of its employees responsible for any expenses or damages incurred as a result of my child’s behavior. I also

understand that any violation of the school’s code of discipline may result in exclusion from the team.

Initial_____

I understand that it is necessary for my child to have an approved medical certificate for school competition on

file in the school before trying out, practicing or competing in interscholastic athletic activities. I agree to inform

the school of any change in my child’s medical or physical condition which develops or is discovered at any time

after the date this document is signed. Initial_____

I understand that with the participation in sports comes the risk of injury, particularly with contact sports. Such

injuries may include, but not be limited to, concussions, and injury to bones, neck, spine or internal organs. I

understand the risks involved and expressly agree to accept all the risks existing in the sport in which my child

will be participating. Initial_____

I have received and read the "Concussion information Sheet". I agree to thoroughly read through the information

sheet and report to the school if there is any change in my child medical condition. Initial_____

I agree that in the event of injury or illness, the staff member in charge of the team may act in my behalf and at

my expense in obtaining medical treatment for my child. Initial_____

I agree to be responsible for the return of all equipment issued by the school to him/her. Initial_____

I understand and give permission for my child to travel unaccompanied on public transportation or accompanied

on a DOE approved bus to and from all scheduled practices and competitions. Initial_____

I hereby give permission for my child’s photograph and information about my child’s performance in PSAL

10.

activities, together with my child’s name, school and grade level to be put on the

website, in

accordance with the policies set forth in the DOE’s Internet Acceptable Use Policy. Initial_____

I understand that the information to be posted does not include information from my child’s academic, guidance,

11.

permanent or cumulative record (i.e. grades or attendance records). I also understand that the information to be

posted does not include other personally identifiable information such as my child’s address, telephone number

or social security number. Initial_____

12.

I hereby give permission for my child to be interviewed, videotaped and/or photographed by the media as it

pertains to PSAL athletic contests. I also hereby release the Department of Education of the City of New York,

and its agents and employees, from all claims, demands, liabilities whatsoever in the connection with the above.

Initial_____

13.

I hereby release, discharge, the New York City Department of Education, the City of New York, the New York

City Public Schools Athletic League, and their employees of all claims, demands or causes of action which are in

any way connected with my child’s participation in this activity, except if such claims arise out of the gross

negligence or willful misconduct of the New York City Department of Education, the City of New York, the

New York City Public Schools Athletic League or their employees. Initial_____

In case of emergency, please contact me at: (____) ___________________ or (____) ________________________

__________________________________ ______________________________________

____/_______/______

PRINT – PARENT/GUARDIAN

SIGNATURE

DATE

I have found the medical certificate submitted by student and parent to be acceptable.

__________________________________

____/______/_______

TEACHER/COACH SIGNATURE

DATE

Rev. 08/12

Interscholastic Athletics Parental Consent Form

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