FRANKLIN COUNTY MIDDLE SCHOOL

PARENTAL CONSENT TO PARTICIPATE / EMERGENCY MEDICAL RELEASE

2010-2011

PART ONE: STUDENT/PARENT CONTACT INFORMATION

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Student First Name MI Last Name

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Home Address City State Zip Code

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Home Telephone Number Preferred Contact Number Student Birthdate

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Mother’s Name Work Telephone Father’s Name Work Telephone

PART TWO: PROOF OF INSURANCE

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Insurance Company Policy # Group #

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Family Physician Telephone Family Dentist Telephone

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Emergency Contact Name Relationship Telephone Number

STUDENT PARTICIPANTS MUST PROVIDE PROOF OF INSURANCE TO PARTICIPATE. INCOMPLETE FORMS WILL BE RETURNED.

PART THREE: STUDENT ACTIVITIES PARTICIPATION AGREEMENT

This application to compete in interscholastic athletics for Franklin County Middle School is entirely voluntary on the part of the parent and student and is made with the understanding that the student has not violated any of the eligibility rules and regulations of the Georgia School Standards or those of the Northeast Georgia Interscholastic Athletic Association. By submitting this application, the student agrees to adhere to the rules and regulations set forth by the Franklin County Middle School and the rules established for individual activities by coaches. It is understood that the student and parent will be responsible for any and all athletic equipment/uniforms issued to the student for practices or games. If any equipment or uniforms are damaged or lost due to negligence, it will be the responsibility of the parent to financially reimburse the school for repair or replacement of the items.

Each student must have his/her parent’s or guardian’s signed permission to participate. All athletic participation requires a current pre-participation physical examination with the doctor’s permission and clearance to participate (physicals are valid for one year from date of issue). The participant is required to abide by all the rules and regulations of the State Board of Education, the Franklin County Board of Education, the Franklin County Student Code of Conduct (6 – 12), the Franklin County Middle School Student Handbook, and the Georgia High School Association.

PART FOUR: PARENT/GUARDIAN PERMISSION/EMERGENCY MEDICAL RELEASE

I have read and understand the student activities participation agreement and I give consent for the above named student

1. To represent Franklin County Middle School in athletic activities approved by the Georgia School Standards commission, Northeast Georgia Interscholastic Athletic Association and the Franklin County Board of Education; and

2. To accompany any school team of which he/she is a member on any local or out-of-county athletic trip; and

3. To participate in the following sports/activities at Franklin County Middle School for the 2010-2011 school year (please initial each sport for which the parent/guardian is providing permission to participate):

_____ Auxiliary _____ Cross Country _____ Tennis

_____ Cheerleading _____ Basketball _____ Track

_____ Girls’ Softball _____ Soccer _____ Baseball

_____ Football _____ Golf

4. I authorize the school to obtain, through its own choice, any emergency medical care that may become reasonably necessary for my son/daughter in the course of such athletic activities or travel. I authorize the school to take such emergency actions as may be deemed necessary, including the transportation of the student to a hospital or medical center and authorization of medical treatment. I hereby grant permission also to said physician to treat said condition unless I am present and request otherwise. I also agree not to hold the school or anyone acting in its behalf responsible for any injury occurring to the above named student in the course of such athletic activities or travel. I assume the responsibility for any medical expenses which may be incurred during an emergency. The coach, school, or the Franklin County School System will not be held responsible for any medical expenses.

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Print Parent Name Parent Signature Date

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Print Student Name Student Signature Date