I request permission for ______________________________________________

Name of Student

To participate in the:

I recognize the extent of the reasonable and prudent responsibilities of the school as well as those of my son/daughter by set school regulations and policy.

In the event of an emergency all doctors require parental consent before administering treatment. In the event that I cannot be reached in an emergency, I hereby give my consent to have ___________________________ treated by a physician and/or hospital.

I certify that ____________________________ is in good physical condition, or that I have listed any and all specific conditions on the back of the form.

Parent’s or Guardian’s Signature _______________________ Date ___________

Home Phone and Emergency Phone _________________ __________________