School Activities Permission Form

Owensville High School

To be completed by student or parent:

Date: __________________________ Grade:________________

Name:_________________________________________________________

Last First Middle

Address:_______________________________________________________

Street

___________________________________ Phone:( )________________

City/State Zip

Birthdate:___________________________ Age:_________ Sex:________

Emergency Contact Person:_______________________________________

Phone:( )____________________________

Family Doctor:__________________________________________________

City/State:_____________________________ Phone:( )_____________

In the space below list any medical information that a sponsor/coach should be made aware of:

This application to represent Gasconade County R-2 Schools in interscholastic activities is entirely voluntary on my part and is made with the understanding I have studied and understand the eligibility standards that I must meet to represent my school that I have not violated any of them. I also understand that if I do not meet the citizenship standards set by the school or if I am ejected from an interscholastic contest because of an inappropriate act, it could result in me not being allowed to participate in the next contest or suspension from the team either temporarily or permanently.

I have completed and/or verified that part of the certificate which requires me to list all previous injuries or addition medical conditions that are known to me which may affect my performance in so representing my school, and I verify that it is correct and complete.

Student’s Signature:_____________________________________ Date:_________________

Parent permission and Authorization for Treatment

We hereby give our consent for the above student to represent his/her school in interscholastic activities. We also give our consent for him/her to accompany the team on trips and will not hold the school responsible in case of accident or injury whether it be in route to or from another school or during practice or an interscholastic contest, and we hereby agree to hold the school district of which this school is part, its employees, agents, representatives, coaches and volunteers harmless from any and all liability, actions, causes of action, debts, claims or demands of every kind and nature whatsoever which may arise by or in connection with participation by my child/ward in any activities related to the interscholastic program of his/her school.

If we cannot be reached and in the event of an emergency, we also give our consent for the school to obtain through a physician or hospital of its choice, such medical care as is reasonably necessary for the welfare of the student, if he/she is injured in the course of school interscholastic activities. We understand that the school may not provide transportation to all events, and permit/do not permit (CIRCLE ONE) my child to drive his/her vehicle in such a case.

We further state that we have completed that part of this certificate which requires us to list all previous injuries or additional medical conditions that are known to us which may affect this student’s performance or treatment; we certify that it is correct and complete.

The MSHSAA By-Laws that a student shall not be permitted to practice or complete for a school until it has verification that he/she has basic insurance coverage. Our son/daughter is covered by basic accident insurance for the current school year with:

____________________________________________________________________________

(Name of Insurance Company)

____________________________________________________________________________

(Policy Number) Date

Parents or Guardian’s Signature:___________________________________________________________

Date

_____________________________________________________________________________________

Date