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Consent Forms |
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WINNISQUAM REGIONAL SCHOOLS ATHLETIC DEPARTMENTACKNOWLEDGMENT
OF WARNING AND CONSENT AGREEMENT **THIS FORM IS FILLED OUT FOR EVERY ATHLETE EACH SEASON**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. 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:
__________________________________________ Address: __________________________________________________ Home Phone: __________________
Business Phone: __________________ In order to participate in the first day of tryouts you
will need to have the following: 1.)
Consent Form
2.) Medical Authorization Form (Both Filled Out) 3.) Physical form completed (1 physical for 4 years of HS / 1 for 3
years of MS) 4.) Proof of insurance (photo copy of card is fine) Types
of Injuries Associated with Each Sport 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.
ATHLETIC DIRECTORS COPY Student’s Name: ______________________________Grade: _______ DOB ____/____/_____ Winnisquam
Regional School District Athletic Department
Medical
Authorization Form
In the
event that I cannot be reached and/or the team is out of the district
during an interscholastic event, I hereby authorize and give permission to
the designated WRSD coach, if it is deemed necessary, to take my child to
the nearest hospital for medical treatment.
I further understand that all expenses and liability for said
expenses incurred with respect there to shall be fully assumed by me. ________________________________________________________________________ Medical Allergies _________________________________________________________________________ Insurance Co / Policy Number ________________________________________________________________________ Signature of Parent or Guardian
Phone # ________________________________________________________________________ Inclusive Dates
Date of Last Tetanus Shot ----------------------------------------------------------------
COACHES COPY Student’s Name: _______________________________Grade: ______ DOB ____/____/_____ Winnisquam
Regional School District Athletic Department
Medical
Authorization Form
In the
event that I cannot be reached and/or the team is out of the district
during an interscholastic event, I hereby authorize and give permission to
the designated WRSD coach, if it is deemed necessary, to take my child to
the nearest hospital for medical treatment.
I further understand that all expenses and liability for said
expenses incurred with respect there to shall be fully assumed by me. ________________________________________________________________________ Medical Allergies ________________________________________________________________________ Insurance Co / Policy Number ________________________________________________________________________ Signature of Parent or Guardian
Phone # ________________________________________________________________________ Inclusive Dates Date of Last Tetanus Shot |
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Winnisquam Regional Middle
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76 Winter Street Tilton, NH 03276
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