PUTNAM VALLEY SCHOOL DISTRICT
DEPARTMENT OF INTERSCHOLASTIC ATHLETICS
Athletic Participation Form
PERMISSION TO PARTICIPATE
I give permission to my child _________________________________to participate in the Putnam Valley School
(Name of child)
District_______________________________program. It is my understanding that my child will comply with the
(Sport and Level) established policies Putnam Valley School District and the Athletic Department. I will assume responsibility for paying fines incurred by my child for loss and/or damage to equipment, supplies, and uniforms with the exception of normal wear.
________________________________________
(Parent /Guardian Signature)
___________________________________
(Date)
SPORTS WARNING
We are aware that playing or practicing in any sport can be a dangerous activity involving MANY RISKS OF INJURY.
We understand that the risks of engaging in the sport of __________________________include, but are not limited to, death, serious neck and spinal injuries which may result in complete or partial paralysis, brain damage, serious injury to virtually all bones, joints, ligaments, muscles, tendons and other aspects of the musculoskeletal system and injury or impairment to other aspects of the body, general health and well being.
We also understand that the dangers and risks of engaging in the above sport may result not only in serious injury, but in a serious impairment of the future abilities of the athlete to earn a living and engage in business, social and recreational activities and generally to enjoy life.
Because of the risks described above, we recognize the importance of listening to and following all of the coach’s instructions and warnings regarding playing techniques, training methods, rules of the sport and other team rules. We therefore, expressly agree to obey all of the coach’s instructions and warnings.
It is acknowledged that we have read and understand the implications of this sports warning.
___________________________________________
(Parent/Guardian Signature) (Date)
________________________________________________
(Signature of Athlete)
(Date)
EMERGENCY MEDICAL TREATMENT
TO BE KEPT IN THE FIRST AID KIT
Student Name:_____________________________ Address __________________________________ Date of Birth___________
In the event that I cannot be reached and my child requires emergency medical attention, I hereby grant permission to a licensed physician designated by the Putnam Valley School District coaching staff to attend to my son/daughter in an appropriate medical setting. ______________________________________________
Grade _________ Sport/Level ________________________
(Parent/Guardian Signature)
(Date)
Parent E-Mail___________________________________
MEDICAL & EMERGENCY INFORMATION
Allergies:________________
Asthma:_________________
Medications:__________________________________
Last Tetanus Shot:_____________________________________Preferred Hospital:______________________________
Home Phone______________
Cell:____________________
Parent Work Phone_____________________________
Family Physician/Phone Number:______________________________________________________________________
Family Dentist/Phone Number:________________________________________________________________________
Emergency Contact & Phone # (other than parent) -1)______________________________________________________
Emergency Contact & Phone # (other than parent)- 2)______________________________________________________
Health Insurance Company:_____________________
Name of Insured:_____________________________________
Insurance ID#:_____________________________ Group #:____________________________________________
MEDICAL HISTORY UPDATE
Student Name__________________________________Sport______________________________________Grade_______
Coach:_________________________
Date of Physical
