REVISED JANUARY 2021
Page 4 of 4
PART IV- ACKNOWLEDGEMENTS OF RISK AND INSURANCE STATEMENT
(To be completed by parent/guardian)
I give permission for _____________________________________ (name of child/ward) to participate in any of the
following sports that are NOT crossed out: baseball, basketball, cheerleading, cross country, field hockey, football, golf, gymnastics,
lacrosse, soccer, softball, swim/dive, tennis, track, volleyball, wrestling, other (identify sports): _______________________________
I have reviewed the individual eligibility rules and I am aware that with the participation in sports comes the risk of injury to my child/ward. I understand that the degree of danger and the seriousness of the risk varies significantly from one sport to another with contact sports carrying the higher risk. I have had an opportunity to understand the risk inherent in sports through meetings, written handouts or some other means. He/she has student medical/accident insurance available through the school (yes__ no__); has athletic participation insurance coverage through the school (yes__ no__); is insured by our family policy with:
Name of medical insurance company: _____________________________________________________________________________
Policy number: ______________________________________ |
Name of policy holder: _______________________________ |
I am aware that participating in sports will involve travel with the team. I acknowledge and accept the risks inherent in the sport and with the travel involved and with this knowledge in mind, grant permission for my child/ward to participate in the sport and travel with the team.
By this signature, I hereby consent to allow the physician(s) and other health care provider(s) selected by myself or the school to perform a pre-participation examination on my child and to provide treatment for any injury or condition resulting from participation in athletics/activities for his/her school during the school year covered by this form. I further consent to allow said physician(s) of health care provider(s) to share appropriate information concerning my child that is relevant to participation in athletics and activities with coaches and other school personnel as deemed necessary.
Additionally, I give my consent and approval for the above named student’s picture and name to be printed in any high school or VHSL athletic program, publication or video.
To access quality, low-cost comprehensive health insurance through FAMIS for your child, please contact Cover Virginia by going to www.coverva.org or calling 855-242-8282.
PART V- EMERGENCY PERMISSION FORM*
(To be completed and signed by the parent/guardian)
STUDENT’S NAME: ____________________________________________ GRADE: __________ AGE: _______ DOB: ______________
HIGH SCHOOL: ___________________________________________________________ CITY: _______________________________
Please list any significant health problems that might be significant to a physician evaluating your child in case of an emergency:
____________________________________________________________________________________________________________
PLEASE LIST ANY ALLERGIES TO MEDICATIONS, ETC: _________________________________________________________________
____________________________________________________________________________________________________________
IS THE STUDENT CURRENTLY PRESCRIBED AN INHALER OR EPI-PEN? ______ LIST THE EMERGENCY MEDICATION: ________________
IS THE STUDENT PRESENTLY TAKING ANY OTHER MEDICATION? _______ IF SO, WHAT? ____________________________________
DOES THE STUDENT WEAR CONTACT LENSES? ______________________ DATE OF LAST Tdap OR Td (TETANUS) SHOT: ___________
EMERGENCY AUTHORIZATION: In the event I cannot be reached in an emergency, I hereby give permission to physicians selected by the coaches and staff of ____________________________________ High School to hospitalize, secure proper treatment for and to
order the injection and/or anesthesia and/or surgery for the person named above.
DAYTIME PHONE NUMBER (WHERE TO REACH YOU IN AN EMERGENCY): _________________________________________________
EVENING TIME PHONE NUMBER (WHERE TO REACH YOU IN AN EMERGENCY): ____________________________________________
CELL PHONE NUMBER: ____________________________________________
→SIGNATURE OF PARENT/GUARDIAN: ________________________________________________ DATE: _____________________
RELATIONSHIP TO STUDENT: ____________________________________________________________________________________
*Emergency Permission Form may be reproduced to travel with respective teams and is acceptable for emergency treatment in needed.
→I CERTIFY ALL OF THE ABOVE INFORMATION IS CORRECT: __________________________________________________________
Parent/Guardian signature