Sr Permission Form

Athletes’s Name______________________________________________ Date of Birth______________

Class of _________

Section_______________

I give permission for my son _______________________________ to participate in interscholastic sports at St. Rita of Cascia High School. I acknowledge that we have read and understand the school athletic standards including the IHSA academic and steroid policies outlined in the student handbook as well as the reverse side of this form. I understand the rules and the consequences that will be enforced. I understand that it is my responsibility as a parent/guardian to notify the St. Rita Athletic Department if my son has a medical condition and to discuss treatment options. I understand that my son’s participation in the athletic program is voluntary and my son and I are free to choose not to participate. By completing this form with my signature, I affirm with full knowledge to release St. Rita of Cascia High School and all their employees, agents, volunteers and any and all individuals and organizations assisting or participating in the St. Rita Athletic Program from any and all claims, rights of action and causes of action that may have arisen in the past or may arise in the future, directly or indirectly from personal injuries to my son or property damage resulting from my son’s participation in the St. Rita of Cascia High School Athletic Program. Please check ALL sports that your son MAY participate in during the 2008-09 school year. Fall: ( ) Football ( ) Flag Football

( ) Soccer

( ) Cross Country

Winter: ( ) Basketball

( ) Wrestling ( ) Bowling

Spring: ( ) Baseball ( ) Water Polo ( ) Track Lacrosse

( ) Golf

( ) Swimming ( ) Hockey ( ) Rugby

( ) Volleyball ( )

Please Provide Necessary Medical Information Below Condition Life Threatening Allergy (food, insect, medication, other) Asthma (Type, Medication) Shortness of Breath Heart Disease or Heart related issues Diabetes (Type, Medication) Head Injury/Concussion Heat Intolerance Sickle Cell Anemia Convulsions Seizures

Yes

No

Explanation/Medication

Chest Pains on exertion Other Medical Conditions:

(Please complete required information on reverse side)

St. Rita of Cascia High School Athletic Registration/Medical Form Page 2

IHSA Steroid Policy

IHSA Academic Policy

As a student athlete, may signature below indicates that I have read and understand the above Steroid and Academic Policies and the penalties associated with them. Student Signature ___________________________________________________ ID#__________________ Address:___________________________________________________________________________________ ___ Home Telephone _____________________________ ________________________________

Family Email

Father/Guardian Name: ___________________________________ ____________________________

Phone #:

Mother/Guardian Name: __________________________________ ____________________________

Phone #:

Insurance Company/Plan: _________________________________ ____________________________

Policy #:

Family Physician: ________________________________________ ____________________________

Phone #:

List two people who will be able to assume care and transport your son home in case of illness. Name: __________________________________ Relation: ___________________ Phone#: __________________ Name: __________________________________ Relation: ___________________ Phone#: __________________

In case of accident/injury and I cannot be reached, I hereby authorize the St. Rita coach, Athletic Trainer, or school administrator to arrange transportation to the nearest hospital and for my son to be treated by the hospital physician on duty. Parent/Guardian Signature: _________________________________________________ Date: _______________

Please provide a copy of most recent physical exam. Athletic Department use only: Date of Physical Exam: __________________

Athletic Staff Initials: _________