WINNISQUAM REGIONAL SCHOOLS
ACKNOWLEDGMENT
OF WARNING AND CONSENT AGREEMENT
Instructions: Please read the ENTIRE form. IF there is
anything about this form or the described activity that you do not understand,
do not sign the form until you are satisfied that you have obtained a compete
explanation. PLEASE FILL IN ALL THE BLANKS. If you have more than one child
participating, complete one form per child.
I/WE, _________________________________________ am/are the
parent (s)
of _________________________________ DOB ___/____/ _____ A
minor, who desires
to participate in the following sport:
________________________
Grade: ________
(1
Sport only)
I/WE
acknowledge that I /WE have been informed as to the nature of the sport, and
that this sport has risks of injury associated for those who participate,
including transportation from and to the school campus. Although the school
staff will endeavor to provide each participant with due care, the school cannot
ensure that my/our child will remain free of injury.
I/WE
represent that our child is physically fit to participate in this sport and, if
required, that he/she has been examined by a licensed physician who verifies
that my/our child is physically fit to participate in this particular sport.
(The School District provides physicals as required by the NHIAA. However, if an
athlete has suffered an injury, or been under the care of a physician for an
illness, verification by a licensed physician may be required.
I/WE
understand that the school has an obligation to take reasonable precautions for
safety and well-being. Our child also has a responsibility for his/her safety
and the safety of others.
I/WE
acknowledge that I/WE must provide the athletic staff with any medical or other
information which I/WE feel is important for the school to know regarding our
son/daughter. This information must be kept confidential. I /WE will provide
medical and any other information on our child prior to the start of practice
for this sport. The school district will rely on me/us to provide this
additional information.
I
/WE acknowledge my/our child must adhere to all the rules, regulations and
instructions pertaining to the safety and protection of the participants, and
that failure to comply could exclude my/our child from participation in this
sport.
** Please
fill out the backside of this page as well **
I/We acknowledge and understand the risks and requirements
for our child to participate in the sport of ________________________________.
I/WE consent to my /our child’s participation in this sport.
Parent / Guardian:
__________________________________________
(Signature)
Address: __________________________________________________
__________________________________Zip
_____________
Home Phone: __________________
Business Phone: __________________
EMAIL: ____________________________________________________________
RETURN THIS FORM TO THE ATHLETIC DIRECTOR.
Basketball: Sprains, strains, contusions, abrasions, concussions,
blisters, cramping, more serious injuries
Baseball
/ Softball:
Sprains, strains, contusions, fractures, eye damage, punctures, dislocations,
and more serious injuries.
Cross
Country:
Sprains, strains, abrasions, blisters, cramping and more serious injuries.
Football
/ Wrestling:
Sprains, strains, contusions, concussions, abrasions, knee and ankle, back and
neck problems and more serious injuries.
Golf:
Sprains, strains, upper and lower back problems and more serious injuries.
Soccer
/ Field Hockey:
Sprains, strains, concussions, fractures, eye damage, punctures, and more
serious injuries.
Spirit:
Sprains, strains, concussions, fractures, dislocations, knee and ankle problems,
and more serious injuries.
Track
& Field:
Sprains, strains, abrasions, blisters, and cramping along w/ more serious
injuries.