INCARNATION SCHOOL SPORTS PERMISSION SLIP
Student’s Name: ________________________________ Grade: ______________
Home Address: __________________________________ Home Phone No. ___________________
Please check the team that your child is trying out for:
_____ Boys’/Girls’ "B" Basketball Team _____ Boys’/Girls’ "B" Football Team
_____ Girls’ "A" Softball Team _____Boys’/Girls’ "A" Basketball Team
_____Boys’/Girls’ "A" Volleyball Team _____ Girls’ "B" Volleyball Team
_____Youth Basketball Team (Grade 1-4) _____Track & Field Team
_____Golf "B" Team _____Cheerleading "B" _____Swimming
(Note: a $30 for B sports and $50 for A sports fee per student is required if on the team.)
The above team will be practicing at the following address(es): _______________________________
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The above team will be playing games at the following location(s): ____________________________
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The practices are scheduled for ________________________________ at _____________ p.m.
The games will be held on ____________________________________ at _____________ p.m.
TRANSPORTATION IS NOT PROVIDED BY THE SCHOOL
Medical Release & Information
Medical Insurance Carrier: _______________________________ Policy No.____________________
Does this player have any disabilities, handicaps, present injuries or limitations, allergies, asthma, or any other medical condition that might affect his/her ability to play the sport listed above? _____ Yes
_____ No Explanation: ___________________________________________________________
Is this player required to take any medication? _____ Yes _____ No
Type/Reason medication taken: ________________________________________________________
Family Doctor: _________________________________ Doctor’s Phone No. __________________
Emergency Authorization:
I, the undersigned parent or legal guardian of the named child (a minor), do hereby authorize the Coach(es) of named Player’s team, or an Incarnation Faculty Member, as my Agents to consent medical, surgical or dental examination and/or treatment for said child. In the case of emergency, I hereby authorize treatment and/or care at any Hospital or Trauma Center. I understand that my insurance benefits that are effective have limited application.Date: ______________________________ Signature: _________________________________________
Waiver of Liability and Disclaimer: I request that my child be permitted to participate in the above athletic activity. I agree to instruct my child to cooperate and conform to directions and instructions of the coach(es) in charge at the time. I do hereby give my consent and agree to release and hold harmless Incarnation School, its officials, managers, coaches, board members and representatives from any and all claims arising out of injury to my child or conditions caused or aggravated by any medical care obtained or by my refusal to obtain available medical treatment for my child for any reason.
Date: _______________________________ Signature: _________________________________________
No student may attend/participate in any athletic activity without this signed parent permission form. Permission may not be given over the telephone.