Marblehead Public Schools Interscholastic Sports Information and Authorization

Name
(Last)__________________ (First)______________________ Middle Initial _____

_______________________________________________________________________
(Street Address) (Town) (Zip Code)

_______________________ _________________
Date of Birth Year of Graduation

Please Print Parent/Guardian Name: _______________________________________

Tel#(H) __________________Tel#(W)__________________ Tel#(C) ______________

IF ABOVE NAMED PARENT/GUARDIAN CANNOT BE REACHED IN AN EMERGENCY, PLEASE CALL:

_______________________________________________________________________
Name Tel# Relationship

List Allergies/Medications/Other Conditions (if not in violation of confidentiality)
________________________________________________________________________

________________________________________________________________________

Athlete's Dr. ___________________________________ Tel # ____________________

Health Insurance _______________________________ Policy # _________________
Our Athletic Insurance provides coverage for eligible expenses unpaid by your own insurance/health plan. Claims must be filed within 90 days.

*I authorize the Athletic Director and/or Athletic Trainer to act for me according to their best judgment in any emergency requiring medical attention when unable to reach me.

*I give permission to the Athletic Trainer to share appropriate medical and treatment information to coaches, other medical personnel and the Athletic Director as deemed necessary for my child's health and safety.

*I further understand that all rules and regulations in the Student Handbook apply to this athlete.

*I recognize that participation in sports in inherently dangerous even when all reasonable precautions are taken. My child participates voluntarily and I accept the inherent risks to which the athlete exposes him/herself and I give permission for him/her to participate.

________________________________________________________________________
Signature of Parent/Guardian (required for participation)