## Preston High School Athletics Permission Slip

### Emergency Information/Agreement/Waiver and Release

(Required for all students participating in this Activity) 2 signed originals of this form are required. One original accompanies the student. The other is kept on file in the Min Office.

#### I/We, the undersigned, request that my/our child be permitted to participate in the activity named below.

####### STUDENT’S NAME: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ GRADE:\_\_\_\_\_\_\_ PHONE:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ STUDENT CELL

SPORT:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ COACH’S NAME: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (NAME & ): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ PRACTICE LOCATION LOCATION WEEK: \_\_\_\_\_\_\_\_\_\_\_ DAYS/TIME(S):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ PRACTICES PER PRACTICE (IF NEEDED): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ MODE OF TRANSPORTATION TO PRACTICES

####### SPECIAL \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ SPECIAL \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

####### PARENT/GUARDIAN NAME: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ PHONE: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ CELL ADDRESS: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ PARENT MAILING PHONE: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ PHONE: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ PARENT HOME WORK CONTACT: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ PHONE: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ADDITIONAL EMERGENCY

### MEDICAL RELEASE

In the event of accident or emergency, when a parent/guardian is unavailable, I hereby authorize a representative of the school to make such arrangements as he/she considers necessary for my child to receive medical/hospital care, including necessary transportation. Under such circumstances, I further authorize the Physician named below to undertake such care and treatment of my child as he/she considers necessary. In the event that said Physician is not available, or I have not provided this information, I authorize such care and treatment to be performed by a licensed physician or surgeon. Furthermore, I understand that as the child’s parent/guardian, I am responsible to pay all costs incurred as a result of the medical emergency. \_\_\_\_\_\_\_ (parent initials)**

###### Physician’s Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Phone #: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

###### Medical Insurance: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Policy #: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

### RELEASE RELEASE OF CLAIMS AGAINST PRESTON HIGH SCHOOL THE SISTERS OF THE DIVINE COMPASSION

As Parent/Guardian, I have voluntarily applied, on behalf of my child, to participate in the above activity. I understand that there are risks in my child’s/ward’s presence, transportation, and participation in this program. I hereby agree on behalf of my child to assume any and all risk of bodily injury, death or property damage, arising out of or caused by my child’s/ward’s presence and participation in this activity. I hereby release Preston High School, the Sisters of the Divine Compassion, and any of their affiliated organizations, agents, and employees, from all actions or claims that my child, my child’s heirs and/or legal representatives now have or may hereafter have for bodily injury, death, and property damage resulting from my child’s/ward’s participation in this activity. I have carefully head this agreement and am aware that this is a release of liability and an agreement between myself on behalf of my child/ward and the school. I signing this document of my own free will. \_\_\_\_\_\_\_\_\_ (parent initials)**

### BEHAVIOR EXPECTATIONS

I agree that the supervising personnel have the right at their discretion to enforce the established rules of conduct, and I agree to instruct my child to cooperate and follow the directions of the supervising personnel.

##### Parent/Guardian Signature**: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_