Dekalb County Sport Physical Form – Fill Out and Use This PDF

DEKALB COUNTY ATHLETIC PARTICIPATION CONSENT FORM

(Physicals must be on or after April 1, for the next school year) Three parental signatures required. All information must be provided.

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NAME:________________________________________________________Male _____ Female _______

(Last)(First)(Middle)

Address: ______________________________________________________________________________

(Street)(City)(Zip)

Student lives with: _________________________________________ Relationship: _________________

(indicate parents, mother only, father only, aunt, brother etc.)

Telephone: Home __________________ Work___________________ Cell______________________

This information is for the school year 2____ - 2_____. Your grade level will be ______ (7, 8, 9, 10, 11, 12)

PARENTAL CONSENT FOR ATHLETIC PARTICIPATION

By its nature, participation in inter-scholastic athletics and intra-scholastic sports clubs includes a risk of injury which may range in severity from minor to long term catastrophic, including permanent paralysis or death. Although serious injuries are not common in supervised athletic programs or athletic clubs, it is possible only to minimize, not eliminate this risk.

Participants have the responsibility to help reduce the chance of injury. Participants must obey all safety rules, report all physical problems to their coaches or club supervisors follow a proper conditioning program and inspect their equipment daily.

I (We) hereby give consent for ____________________________________ to:

(Print full name)

1)Compete in athletics in the Dekalb County School District in the following Georgia High School Association approved Sport(s)

(Please circle each sport you approve)
Baseball	Basketball	Golf	Volleyball	Swimming & Diving Lacrosse
Gymnastics	Cross Country	Football	Softball	Wrestling
Tennis	Rifle Team	Soccer	Track & Field	Cheerleading

2)To accompany any school team or sports club of which the student is a member on any of its local or out of town trips excluding over-night trips. I understand that transportation may or may not be provided by the DeKalb County School District. (In the event transportation is not provided by the School District, transportation will be the student’s responsibility.)

3)I release and waive, and further agree to indemnify, hold harmless or reimburse the DeKalb County School District, the Board of Education, its successors and assigns, its members, agents, employees and representatives thereof, as well as trip supervisors, from and against any claim which I, any other parent or guardian, any sibling, the student , or any other person, firm or corporation may have or claim to have, known or unknown, directly or indirectly, from any losses, damages or injuries arising out of, during , or in connection with the student’s participation in the activity, any trip associated with the activity, or the rendering of emergency medical procedures or treatment if any.

4)I have insurance for coverage of my son/ daughter in the form indicated below. (Please initial by the type of insurance coverage you have. (You must provide a copy of the insurance card or policy benefits as indicated.)

_____ My son/daughter is adequately and currently covered by accident insurance that will cover injuries sustained while participating in inter-scholastic Athletics (including, but not limited to, Varsity and Junior Varsity Football) and inter-scholastic clubs and activities. (Attach copy of card)

Insurance Company Name: _______________________________________

Name of Insured:	_______________________________________
Policy number:	_______________________________________

_____I have purchased the Benefit Plan provided by the DeKalb County School System. (attach a signed copy of benefit plan)

5)I hereby verify that the information on this form is correct and understand that any false information may result in my son/ daughter being declared ineligible.

(Students found illegally enrolled out of their school attendance zone could be ruled ineligible for GHSA competition for one full year.

By signing this permission form, you acknowledge that you have read and understand the risks of participation and agree to the above terms. This acknowledgement of risk and consent to allow participation shall remain in effect until revoked in writing. (Parents or students who do not wish to accept any of these terms or risks should not sign and participation will be denied.)

___________________________________ DATE______________________

SIGNATURE(S) PARENT(S) OR GUARDIAN(S

__________________________________________ DATE____________________________

SIGNATURE OF STUDENT-ATHLETE