Track and Field Cheerleading Youth Basketball(Grades 1-4)

GRADE: ___________________ BIRTHDATE: _____________________________

I, THE PARENT/GUARDIAN OF THE ABOVE NAMED CHILD, HEREBY REQUEST THAT MY CHILD PARTICIPATE IN THE ATHLETIC ACTIVITY LISTED ABOVE. I AGREE TO DIRECT MY CHILD TO CO-OPERATE AND CONFORM WITH DIRECTIONS AND INSTRUCTIONS OF THE SUPERVISORY ARCHDIOCESAN PERSONNEL RESPONSIBLE FOR THE ATHLETIC ACTIVITY.

I AGREE THAT IN THE EVENT MY CHILD IS INJURED AS A RESULT OF HIS/HER PARTICIPATION IN THE ABOVE LISTED ATHELETIC ACTIVITY, INCLUDING TRANSPORTATION TO AND FROM THE ACTIVITY, WHETHER OR NOT CAUSED BY THE NEGLIGENCE (ACTIVE OR PASSIVE) OF THE SCHOOL OR ARCHDIOCESAN ATHLETIC ACTIVITY PROGRAM OR ANY OF ITS AGENTS OR EMPLOYEES, RECOURSE FOR THE PAYMENT OF ANY RESULTING HOSPITAL, MEDICAL OR RELATED COSTS AND EXPENSES WILL FIRST BE MADE AGAINST ANY ACCIDENT; HOSPITAL OR MEDICAL INSURANCE OR ANY AVAILABLE BENEFIT PLAN OF MINE OR OF MY SPOUSE.

I HEREBY GIVE PERMISSION TO THE PHYSICIAN SELECTED BY THE ATHLETIC ACTIVITY SUPERVISORY PERSONNEL THEN PRESENT TO RENDER MEDICAL TREATMENT DEEMED NECESSARY AND APPROPRIATE BY THE PHYSICIAN.

I AM NOT AWARE OF ANY MEDICAL CONDITION OF MY CHILD WHICH WOULD RENDER IT INAPPROPRIATE FOR HIM/HER TO PARTICIPATE IN ANY SUCH ACTIVITY.

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Parent/Guardian’s Name (Please Print) Parent/Guardian’s Signature

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Home Address (Street, City, Zip)

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