Ems Track Registration and Consent Form: Emergency Information

EMS TRACK REGISTRATION and CONSENT FORM
Student Name: _______________________________________Grade: ____________Team:_______
Address: __________________________________________________________________________
Home Phone: ________________ Cell Phone/Pager: _______________Email:__________________
EMERGENCY INFORMATION
Male Parent/Guardian: ___________________________________________________________
Work Phone: ________________________ Cell Phone/Pager: _____________________
Female Parent/Guardian: _________________________________________________________
Work Phone: ________________________ Cell Phone/Pager: _____________________
Family Physicians Name and Address: _____________________________________________
Physicians Phone: ______________________________________________________________
In the event that a parent/guardian cannot be reached:

AUTHORIZED EMERGENCY
CONTACT PERSON: _________________________________ Phone: _________________
Please list any special health concerns and/or emergency information:
PARENTAL CONSENT for Participation, Medical Treatment, and Riding the Bus
_____________________has permission to participate in sports programs at Eagleview Middle School. I understand the
school does not provide student insurance and I am responsible for any medical expenses that may be incurred as a result
of participation in this activity. I also acknowledge there are inherent risks involved in any athletic activity. In
consideration of my child participating in this sport, consent is given for emergency medical treatment, hospitalization or
other medical treatment by a physician and/or hospital in the event of injury or illness, and waive any liability of Academy
School District20, its agents or employees arising out of such medical treatment. _____________________has
permission to ride buses to athletic events and I acknowledge there may be risks involved in riding the bus.
Parent(s) Signature:_____________________________________________Date:________________
__________________________________________Date:_______________
RETURN THIS FORM TO THE ATHLETIC OFFICE

TRACK Registration Fee: $40.00
Please make check payable to: Eagleview Middle School
FOR OFFICE USE ONLY
Amount paid_________ Check no.______Pay4It________Physical________ Roster_______ IC_______
Release for School Sponsored Clubs and Intramural Sport
Activities
Academy School District Twenty strives to provide a safe

environment for school approved clubs and intramural sport
activities that will stimulate and challenge students; we cannot
guarantee an accident will not occur. Voluntary participation in supervised school clubs and sport activities
may be one of the least hazardous environments any student is involved in. However, participation in some
clubs and sports (e.g., karate, skate board, etc.), includes an inherent risk of injury which may range in severity
from minor to long-term catastrophic injury. Although serious injuries are not common in supervised programs,
it is impossible to eliminate all risk.
Students participating in a club or sport activity must obey all safety rules, report all physical problems to the
club or sport activity supervisor and shall be responsible for the safe condition of their own equipment.
By signing this permission form, we acknowledge that we have read and understand this warning and
understand the inherent risks associated with this club or sport activity. We further understand that we are
responsible for obtaining any medical, accident, or other insurance that we deem appropriate; the district does
not provide student accident insurance. The District makes available to parents student accident insurance
information which may be purchased at parents expense.
I understand that the School District and its employees may have certain legal protections and immunities from
liability with respect to any property damage or personal injury that may occur during the activity. The School
District and its employees have not waived these protections and immunities. I understand that the School
District and its employees may also have certain legal obligations with respect to the activity.
By signing this form, I am not releasing the School District and its employees from any of their legal
obligations. However, on behalf of myself, my student, and our family and representatives, I release and
hold harmless the School District and its employees from and against all claims for any damages or
injuries incurred by my student from any cause, including but not limited to my students own
misconduct or the actions or omissions of third parties. I understand that for purposes of this Release, the
term employees includes the School Districts directors, employees, servants, and volunteers.
I hereby give my consent for my child ___________________________________________________
to participate in __________________________________________ at __________________________ School

for either the duration of the club/sport activity or until my student chooses to quit the club/sport activity and I
hereby release the School District and hold it and its employees harmless against any liability for injuries my
student may incur as a result of participating in the club or activity identified above.
Participant Signature (only if over the age of 18)_________________________________ Date:_____
Parent Signature:_______________________________________ Date:_________________________
Emergency Contact Name:______________________________________________________________
Emergency Contact Number:_______________

Updated 5/18/2009
ASSUMPTION OF RISK AGREEMENT TO HOLD HARMLESS
AND EMERGENCY RELEASE FORM
As the parent/legal guardian of the athlete named here ______________________________________ (athletes name),
I/We understand that playing or participating in any sport can be a dangerous activity involving risks of injury, which
may be serious. By signing below, the athlete and parent/legal guardian hereby assume all risks associated with
participation and agree to hold Academy School District 20, the school, camp organization and their agents, coaches,
and volunteers harmless from any and all liability, actions, causes of action, debts, claims or demands of any kind. By
signing below, the athlete and parent/legal guardian confirm that the athlete has been deemed physically able to
participate in athletic activities by a physician. Additionally, by signing below, the athlete and parent/legal guardian, in
the event of a medical emergency in which the parent/legal guardian cannot be reached, grant permission to the
physician selected by the school to hospitalize and secure proper treatment (including surgery) for the athlete and verify
agreement to assume all costs for such treatment. Participants must obey all safety rules, report all physical problems to
their coaches, follow a proper conditioning program, and inspect their own equipment daily. The parent/legal guardian
and athlete agree to abide by all district/school/camp rules and comply with the reasonable authority of the staff.]
This form applies to the following sport/camp/activity:

SPORT:____________________________________________________
Parent/Legal Guardian: Parents/Guardians who do not wish to accept the risks described in this warning should not
sign the permission form.
Parent Printed Name ________________________________Signature_________________________________
Date_________
Home Phone_______________________ Day Phone_______________________ Cell Phone_______________________
Athlete: Athletes who do not wish to accept the risks described in this warning should not sign the permission form.
Athlete Printed Name ________________________________Signature_________________________________
Date_________
Emergency Contact Information:

Emergency Contact Name________________________________ Emergency Contact Phone _______________________
Please return this form and maintain a copy for your records

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EMS TRACK REGISTRATION and CONSENT FORM

Student Name: _______________________________________Grade: ____________Team:_______

Home Phone: ________________ Cell Phone/Pager: _______________Email:__________________

Male Parent/Guardian: ___________________________________________________________

Work Phone: ________________________ Cell Phone/Pager: _____________________

Female Parent/Guardian: _________________________________________________________

Work Phone: ________________________ Cell Phone/Pager: _____________________

Family Physicians Name and Address: _____________________________________________

Physicians Phone: ______________________________________________________________

In the event that a parent/guardian cannot be reached:

RETURN THIS FORM TO THE ATHLETIC OFFICE

Academy School District Twenty strives to provide a safe

I hereby give my consent for my child ___________________________________________________

to participate in __________________________________________ at __________________________ School

Participant Signature (only if over the age of 18)_________________________________ Date:_____

Parent Signature:_______________________________________ Date:_________________________

Emergency Contact Name:______________________________________________________________

Emergency Contact Number:_______________

This form applies to the following sport/camp/activity:

Emergency Contact Information:

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Student Name: _________________________________Grade: Team:_

Home Phone: ________ Cell Phone/Pager: _Email:____________

Work Phone: ____ Cell Phone/Pager: _

Work Phone: ____ Cell Phone/Pager: _

to participate in ________________ at School

Participant Signature (only if over the age of 18)_____________________________ Date:_

Parent Signature:_______________ Date:_