Youth Sport Permission and Participation Form 2005 - '06

NAME OF STUDENT: __________________________________________

ADDRESS: _________________________________________________

TELEPHONE / CELL : _________________________________________

PARENT / GUARDIAN: ________________________________________

E-MAIL ADDRESS: ___________________________________________

EMERGENCY CONTACT: _______________________________________

__________________________________________________________

STUDENT PHYSICIAN: ________________________________________

Telephone / address: __________________________________________

PARTICIPATION FEE: $50.00 [ ] paid / check attached

Note: In order to make after-school sports programs happen, we must collect a small fee that goes toward referees, equipment and other necessary supplies.

CONSENT TO MEDICAL CARE AND TREATMENT

I, ___________________________________, Parent / Guardian authorize all medical, surgical, diagnostic and hospital procedures as may be preformed or prescribed by a treating physician for ___________________________________, if I cannot be reached in the event of an emergency.

I, Parent / Guardian of the above-named student is hereby given my express permission and approval to participate in after-school sports activities at M.C.S. We assume all risks and hazards incidental to the conduct of sports activities, including transportation to or from athletic events. We hereby release, absolve, indemnify and hold harmless M.C.S., organizers, supervisors / coaches appointed my M.C.S.

Signature: ____________________________________ Date : ______________