Fall 2005:
Print out and complete
Mount Everett High School Athletic Permission Form
Physicals.....August
24th: Boys at 8:30; Girls at 10:00
Name:________________________________________
Birth Date:________________
Home Address: Street:__________________________
Town:____________________
Male:______ Female:______ Grade:______
Home Phone:______________
In an emergency, notify:
Name:________________________________________
Phone:___________________
Street:________________________________________
Town:____________________
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In the event that I cannot be reached
in an emergency, I hereby give
permission to the physician selected by the school to hospitalize,
secure proper treatment for, and to order injection , anesthesia or surgery
for my child as named above. I understand that the school is not responsible
for the medical cost of any injury resulting from any sport that my son/
daughter participates in.
Also, the above student has my
permission to participate in the following sport:_________________________
Is there any medical condition that the coach should be aware of? No_____ Yes_____
If yes, what?__________________________________________________________________________________
Parent's Signature:_______________________________________________
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I
understand that to participate in athletics at Mt. Everett, I have obligations
to myself, my team, my coach, my school, and the Massachusetts Interscholastic
Athletic Association to follow certain rules and regulations. I further
understand that to participate in athletics at Mt. Everett, I must not
turn 19 before September 1 of this school year. I realize that I must secure
during the last marking period preceding the contest, passing grades according
to M.I.A.A. guidelines. Academic eligibility shall be considered as official
on the published date when the report cards for that ranking period are
to be issued to the parents of all students.
I will have no involvement with alcohol,
drugs or tobacco, either using them or supporting the use of them illegally,
and I understand that if I violate this rule I will be suspended from the
team according to the M.I.A.A. rules and regulations.
I also understand the attendance at practices
is critical to the overall success of the team. It is important that your
coach is notified by you in advance if you are to miss a practice. Players
may be excused for: academic issues, family, or illness. Your coach will
give you his/her attendance policy at the beginning of the season.
Student's signature:______________________________________________
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For office use only:
Last tetanus booster:________ Academically
eligibility:________ Date of physical:________
Athletic Director's initials:_______ Nurse's
initials:________