2017-2018 Delta Middle School Athletic Registration & Consent to Treat

Consent to Treat STUDENT NAME: __________________________________

GRADE: _________

In the event of serious illness or injury parents will notified as a quickly as possible but this form will allow for immediate treatment of the participant. As the Parent (or Legal Guardian) of the student listed above, in the event of illness or injury, I hereby authorize the sponsors of the activity to authorize such emergency medical attention, as they deem necessary. I further agree that I am responsible to pay all costs associated with this treatment. ________________________ ________________ (Parent/Guard. Name) (Relationship) ________________________ ________________ (Parent/Guard. Signature) (Date) _________________________________________ (Address)

Emergency Contact Information: Name: _____________________________________ Relationship: _____________________________ Phone Number: __________________________

_________________________________________ (Phone Number(s)) Please list any pre-existing conditions or known allergies below: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

Athletic Registration I have had the opportunity to read the Delta County Joint School District #50 Policy JJJ-R (Guidelines for Extracurricular Activities). I fully understand them and hereby consent to all terms and conditions contained herein. I also acknowledge that I have read and understand the document regarding head injuries and health information sharing contained in the aforementioned policy. Furthermore I agree to abide by the rules and procedures adopted by the Delta Middle School Athletic Department and each athletic program. _____________________________ (Parent Signature)

_________________ (Date)

_____________________________ (Student Signature)

_________________ (Date)