Boston Public School Athletics Consent for Treatment, Participation, and Travel

Student Name: __________________________Student #: _______________ Student email: ___________________ Sport/Team: ______________ School: _________________________________ Grade: _______________ HR: _________ Home Address: __________________________________________ Phone: __________________ Parent/Guardian #2: ________________________ Home Phone: _____________________________ Cell Phone: _______________________________

Parent/Guardian #1: _________________________ Home Phone: ______________________________ Cell Phone: ________________________________

Emergency Contact Person(s); Please include phone contact and relationship to student (this information must remain updated. 1._______________________________________________________________________________________ 2._______________________________________________________________________________________ 3._______________________________________________________________________________________ I HEREBY STATE TO THE BEST OF MY KNOWLEDGE, MY ANSWERS TO THE SPORTS MEDICAL QUESTIONNAIRE ARE COMPLETE AND CORRECT AND THAT I GIVE PERMISSION FOR MY CHILD TO PARTICIPATE IN ATHLETIC ACTIVITIES.

Signature of Athlete: ________________________________________ Date: ________________________ Signature of Parent/Guardian: _________________________________ Date: ________________________

Boston Public Schools and its athletic trainers have permission to seek necessary emergency treatment for my child during his/her participation in athletics, practice games, and conditioning.

Signature of Parent/Guardian: _________________________________ Date: _______________________

I acknowledge that there are certain risk inherent in participating in athletic events, In acknowledging these risk and in considering the opportunity to participate in such activity, I hereby agree to hold Boston Public Schools, and their representative subsidiaries and affiliates , and any third party sponsor of the athletic event Harmless against any liability, loss or damage (including reasonable attorneys fees) arising from my childs participation in Boston Public School Athletics, and release and discharge the entities from any claims whatsoever in connection with their participation including claims for personal injury or property damage suffered in connection with their participation and/or travel to the event.

Signature of Parent/Guardian: _______________________________ Date: __________________________

If needed, I hereby authorize dispensation of medication by trained non-nursing personnel as provided by my childs medical provider. I further understand that such trained personnel must be

present (or self medication plan on file) for the administration of medication during athletic events.
Signature of Parent/Guardian: _________________________________ Date: ______________________

I understand that, under state law, parent volunteers and parents/guardians of children who participate in any extracurricular athletic activity must participate in a free SPORT HEAD INJURY and CONCUSSION AWARENESS Course, either on-line or through written materials. By my signature, I attest that I have completed the course.
Signature of Athlete: ________________________________________ Date: ______________________ Signature of Parent/Guardian: _________________________________ Date: ______________________

I am aware that my child may be asked to go on runs close to the track. Long runs can range from 1-2 miles and will require that students run on city sidewalks.
Signature of Parent/Guardian:_________________________________ Date:___________________

In order for photos and videos of the team during practice and competition to be put on our team website, confirmation of the following section of the Boston Public Schools Parent and Student Agreement is needed.

Media Appearances (excerpt from Boston Public Schools Parent Student Agreement)

I give permission for Boston Public Schools to record, film, photograph, interview and/or publicly exhibit, distribute, or publish in print and in electronic media my son/daughters name, appearance, spoken words and works during the 2011-2012 school year, whether undertaken by school staff, students, or anyone outside the school, including the media. I agree that Boston Public Schools may use, or allow others to use, those works without limitation or compensation. I release my childs school and Boston Public Schools staff from any claims arising out of my childs appearance or participation in these works.

I DO NOT give permission for my son/daughters name, appearance, spoken words and works to appear in the media as described above.

Signature of Parent/Guardian:__________________________ Date:______________