Warning of Risk, Waiver of Liability, Parental Consent for Medical Care of a Child, andContact/Medical Information
I am the parent or legal guardian of ______, minor, and have full legal custody and control of the minor.
I here by acknowledge awareness that participation in the sport of ______, involves risk of injury, which may include severe injuries including but not limited to paralysis, permanent mental disability, and death. My signature on the bottomof this formindicates that I understand and accept these risks, and that I agree to waive and release Souhegan High School, the SAU #39 District, it’s employees, officers, and personnel (including volunteer personnel), from any and all liability for any injuries that may occur.
I here by authorize a Souhegan High School representative to consent to whatever medical care (including diagnostic examination, treatment or immunization) that my son/daughter may require during my absence. This authorization is conditioned upon the understanding that, in the event of serious illness or injury or the need for surgery or other major procedure other than in an emergency, the temporary guardian will use all reasonable efforts to contact me. Failure to successfully contact me, however, should not delay or prevent any licensed physician from providing such treatment as may be advised in my child’s best interest.
Souhegan High School – Athletic Certificate of Insurance
A STUDENT IS NOT ALLOWED TO PARTICPATE WITHOUT HEALTH INSURANCE. IF YOU DO NOT HAVE HEALTH INSURANCE YOUR FAMILY WILL NEED TO PURCHASE SUPPLIMENTAL INSURANCE COVERAGE FROM LEFEBVRE STUDENT INSURANCE. THE FORMS TO PURCHASE LEFEBVRE STUDENT INSURANCE CAN BE FOUND ON THE SOUHEGAN HIGH SCHOOLS ATHLETICS PAGE. ANY QUESTIONS PLEASE CONTACT THE SOUHEGAN ATHLETIC DEPARTMENT.
I, ______, hereby certify with my signature on the bottom of this form that I DO have medical / health insurance, which covers my son/daughter______. This policy will provide primary coverage for him / her in the event of injury while in any interscholastic or intramural sport.
Health Insurance Co:______
Health Insurance Group # and I.D. / Policy #:______
I, ______, hereby certify with my signature on the bottom of this form that I DO NOT have medical / health insurance, which covers my son/daughter______. I am aware that I must obtain insurance for my child to participate. SEE INFORMATION ABOVE.
______
Parent/Legal Guardian Printed Parent/Legal Guardian Signature Date
Student Information
Name of Child: ______AGE ______
Name of Parents / Legal Guardians: ______
Home Phone:______Father Phone:______Mother Phone: ______
Student E-mail______Parent E-mail ______
Family Physician:______Phone:______
Is your child a diabetic? YES / NO
Is your child currently using any medications? YES / NO
If yes, what medications? ______
Does your child have any known allergies? YES / NO
If yes, what allergies? ______
Has your child ever been diagnosed with a concussion? YES / NO
If yes, when and how many? ______
Does your child have any know medical conditions, or has your child suffered a prior sport injury? YES / NO
If yes, when and what? ______
Souhegan Athletics SixAcknowledgment
For the privilege of wearing a Saber Uniform, Souhegan High School has set a high standards that Student-Athletes are expected to uphold. The standards, and the consequences for not upholding those standards can be found on the Souhegan Athletic Website under “Souhegan Six – Athletic Standards.” Your signature below indicates that you and your child have read and understands the Souhegan Six – Athletic Standards.
Souhegan Athletics – Participation Fee Acknowledgment
Souhegan High School uses a participation fee to assist in offsetting the cost of offering a broad interscholastic athletic program. The per sport fee is based on the actual cost to field a particular sport. If paying by check the check should be made out to SHS Activities, and must be paid before your child may participate.If a student is cut from the team, or chooses to discontinue his/her participation within five calendar days of the first regular season game the participation fee will be refunded in full. If the student chooses to discontinue participation after five calendar days following the first regular season game the participation fee will not be refunded.
Souhegan has an annual cap of$400 per family. This cap excludes the participation fee for ice hockey. Families are responsible for monitoring their participation fee expenditure and must notify the athletic department in writing no later than May 30th 2014 to request a refund for any portion over the $400 cap. Your signature below indicates that you have read and understand the participation fee policy.
Participation Fee Structure
$100$125$150$300
BowlingAlpine SkiingBaseball Ice Hockey
Cross CountrySoccerBasketball
DanceSwimmingField Hockey
GolfTennisFootball
Nordic SkiingTrack & Field – WinterGymnastics
Spirit VolleyballLacrosse
Track & Field – SpringSoftball
Wrestling
______Parent/Legal Guardian Printed Name Parent/Legal Guardian Signature Date
______Student Name Printed Student Signature Date