ST. PAUL CATHOLIC SCHOOL
ATHLETIC PERMISSION FORM
(To be returned to your coach)

                                            BOY’S
SPORT PLAYED (this season) GIRL’S____________________________________ (circle 1) (FALL) (WINTER) (SPRING)

To be completed by the PARENT/GUARDIAN and STUDENT and returned to the head coach prior to the first day of practice. To be kept on file by the coach.

STUDENT’S___________________________________________________GRADE____________ HOMEROOM_____________
NAME                        (Print clearly) Last Middle First

ADDRESS __________________________________________________________________________________________________
                                                                                    Street - City - State - Zip Code

AGE _____________ DATE OF BIRTH ______________________ PHONE _______________________________

Date ____________ Signature of Student ______________________________________________________

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

PARENT OR GUARDIAN CONSENT

I hereby give my consent for the above student to engage in interscholastic athletics at St. Paul School during the current school year and to accompany the team as a member on its out-of-town trips. I understand that my son/daughter will be expected to adhere firmly to all established athletic policies.

Date ___________ Signature of Parent or Guardian _______________________________________________________________

EMERGENCY INFORMATION
(To be completed by parent/guardian)

PRIMARY EMERGENCY CONTACT:                         SECONDARY EMERGENCY CONTACT :
Parent or Guardian _____________________________________ Parent or Guardian _________________________________________

Home                                     Bus.                                  Home                                      Bus.
Phone _____________________ Phone __________________ Phone _____________________ Phone_______________________

THIRD EMERGENCY CONTACT : In the event parents cannot be contacted, please contact:

Name __________________________________________________________ Relation _____________________________________

Home                                                                Bus.
Phone _____________________________________ Phone ___________________________________________________________

Health Insurance Provider ________________________________________________ Policy # _______________________________

MEDICAL TREATMENT CONSENT

I, _________________________________________ the parent or guardian of the above named student, recognize that as a result of athletic participation, medical treatment on an emergency basis may be necessary and further recognize that school personnel may be unable to contact me for my consent for emergency medical care. I do hereby consent in advance to such emergency care, including hospital care, as may be deemed necessary under the then existing circumstance. I understand this authorization will be enforced when I cannot be contacted and provide for immediate treatment.

Please make the following notations on my son/daughter’s records:

Medications ____________________________________________________

Allergies to medications__________________________________ taken ____________________________________________

Relevant medical information (e.g., contact lens wearer, history of family diabetes, epilepsy, heart murmur)

____________________________________________________________________________________________________________

Date ____________ Signature of Parent or Guardian ______________________________________