St. Rose of Lima School

Medical History and Consent for Athletic Participation

Medical History & Physical Form must accompany this consent form.

Student: _______________________________________    Birthdate:      _________________

Address: ______________________________________    Telephone:     _________________

Telephone where parent can be reached if not at home: _______________________________

Teacher: _____________________                          Grade:  ______________________

ACTIVITY OR SPORTS PROGRAM:  ____________________________________

Date of first practice:  _____________________    Date of Physical:  _____________

I hereby request consideration for placement in the above athletic program.

___________________________________                              ______________________________

Signature of Student                                                                  Date

I hereby give my informed consent for the participation of the above named student in the activity or sports program listed conducted by the school against other schools and within the school.  I acknowledge that even with the best of coaching, use of the most advanced protective equipment and strict observation of rules, injuries are still a possibility.  On rare occasions these injuries can be so severe as to result in total disability, paralysis, or even death.  I acknowledge that I have read and understand this warning.

I certify that the answers to the following Medical History are true and correct and that the above named student does not suffer from any condition which to my knowledge will prevent his/her participation.

I give permission for the St. Rose of Lima School coaching staff to seek medical treatment for my child in case of injury or illness which occurs while participating in school sponsored activities.

____________________________________________             __________________

Signature of Parent/Guardian                                                           Date