Nashua Middle School Athletic Department

Nashua Middle School Athletic Department

36 Riverside Dr.

Nashua, NH 03062-1312

Athletic Director: Thomas Arria

Middle School Coordinators:

Elm St – John Lysik

Fairgrounds – Andy Paul

Pennichuck – John Connolly

Dear Parent/Guardian:

Enclosed is a copy of the Nashua Middle School Packet. Inside you will find the necessary documents to ensure that your son/daughter is eligible to participate in the NMS Athletic Program.

Valid physical examination forms are required in order to participate in athletics for the NashuaSchool District. The physical must be dated on or after July 1st, 2011. All incoming 6th graders or new athletes must show evidence of an examination by this date. This physical will be valid for all sports grades 6-8, barring any change in his/her medical condition.

Middle School student-athletes should return their completed packets to their coach or the Main Office at their respective school (Elm/Fairgrounds/Pennichuck) prior to the beginning of try-outs.

As the Athletic Director for the Nashua School District, I would ask that you assist me in ensuring that your son/daughter have the necessary documentation to participate in our athletic program. Please contact me if you have any questions.

Thank you for your support and cooperation.

Sincerely,

Thomas Arria

NASHUA MIDDLE SCHOOL ATHLETICS

Parental Permission Form

Name______Grade______School: E F P YOG: ______

Date of birth: ______Today’s Date: ______

Address: ______Phone #:______

Parents/Guardians: ______Work or cell phone: ______

Child’s Physician: ______Address & Phone: ______

Sport trying out/participating for this season: (Please circle)

Fall:Boys SoccerGirls SoccerBoys XCGirls XC Volleyball

Winter:Boys BasketballGirls BasketballCheerleading

Spring:BaseballSoftballBoys TrackGirls Track

As a parent/guardian of ______, I hereby give my consent for his/her practice and play in the athletic sport listed above. I also grant permission for treatment deemed necessary for a condition arising during participation in these activities, including medical or surgical treatment recommended by a medical doctor. I understand that every effort will be made to contact me prior to treatment. I further grant permission to the NashuaSchool District to transport my child to and from athletic activities.

( ) Please check the box if there have been any illnesses, injuries, or other changes in your child’s condition since his/her last examination that you feel may affect his/her ability to participate in athletics this year. If yes, please specify date and condition.

Please check those that apply:

( ) My child is covered by a medical and accident policy.

( ) My child is not covered by a medical and accident policy at this time.

( ) I/We chose to purchase the insurance coverage provided by the district at the beginning of the school year.

CONSENT TO PARTICIPATE AND ACKNOWLEDGEMENT OF RISKS

I/we hereby acknowledge awareness that participation in any school sport involves a risk of injury, which may include severe injuries possibly involving paralysis, permanent mental disability, or death, and that these injuries may occur in some instances as a result of unavoidable accidents. I/we accept these risks in giving consent to participate in school sports during the ______- ______school year by the undersigned athlete.

______

Athlete’s Full Name – Please Print Date of Birth

______

Athlete’s SignatureDate

______

Parent/Guardian SignatureDate

Brace Waiver (If Applicable)

I give my permissionfor my child, ______, to participate in sports at ______School while wearing orthodontic braces.

I agree to hold the NashuaSchool District and the Athletic Department harmless for any damage to braces or teeth while participating in the sports program.

______

Parent/Guardian SignatureDate

Serious Conditions or Injuries, Allergies, Medication (If Applicable)

No ______Yes ______

If yes, please specify:

Nashua Athletic Department

Physical Examination/Activity Consent Form

Student Name: ______Date of Birth: ______

Date of Exam: ______

Height: ______Weight: ______Blood Pressure: ______

Hearing: Right ear______Left ear______

Vision: Right eye______Left eye______Glasses: YesNo

Known Allergies:______

Medications in current use:______

Physical Exam:( ) Within normal limits

( ) Other (please comment below)

Allowed to Participate in: (please check one)

( ) All age appropriate sports and school activities

( ) All age appropriate sports and school activities with the following restrictions: Please indicate restrictions below:

Signature/Title (MD, DO, PA-C, ARNP) ______Date:______

Print Name of examiner______

Office Address and Phone #______