Freeport High School Extracurricular Activities Participation Release Agreement _____________________________________ Student’s Name (Please Print)
______________________ Date of Birth (mm/dd/yyyy)
________________________________________ Name of Parent/Guardian (Please Print)
Parent/Guardian of the student named above, hereby gives permission for the student to try out for extracurricular activities including athletic teams at Freeport High School and participate in all of the teams’ activities, as directed by the coach/sponsor. We understand that my child will be obligated to attend regularly scheduled practices and competition. We hereby acknowledge that we have access to the Freeport High School’s Extracurricular Policy Handbook and understand the rules and regulations within. We agree to abide by all the rules and regulations set down by my coach/sponsor and the athletic director. Student will abide by all conduct rules and will behave in a sportsmanship manner. We agree to assume full responsibility for all equipment issued to the student, and to confine the use of that equipment to practice, games, or meets. We will further agree to pay for any and all equipment, which the student may lose, misplace, or damage through carelessness or intent. We acknowledge we have been provided information regarding concussions and the IHSA Performing-Enhancing Substance Policy. We acknowledge we have been informed concerning the consent for the student’s participating in returning to play in accordance with the returnto-play and return-to-learn protocols established by Illinois State law. We understand the risks associated with the student returning to play and returning to learn protocols established by Illinois State law. We consent to the disclosure to appropriate persons, consistent with the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191), of the treating physician’s or athletic trainer’s written statement, and, if any, the return-to-play and return-to-learn recommendations of the treating physician or the athletic trainer, as the case may be. We acknowledge the district’s random substance testing policy as stated in the Extracurricular Activity Policy Handbook. We agree to follow the said policy and procedures, including being subjected to random testing as a condition of participation in extracurricular activities. We understand if the rules are violated that the opportunity to participate in the extracurricular activity can be revoked. We authorize the medical staff to take a sample of saliva, urine, or breath for the purpose of performing tests and otherwise screen the sample obtained for the presence of drugs, alcohol, tobacco, or other chemical substances. Also, we authorize the medical staff and laboratory to release the results of the testing regardless of whether the results are negative or positive to the administration of FSD#145. The consent is valid for the entire high school career unless the student meets the criteria to withdraw from the random drug testing pool. We understand that all sports and extracurricular activities can involve many risks of injury, even death. In consideration of the School District permitting the student to participate in an extracurricular activity(ies), We agree to hold the Freeport School District #145, its employees, agents, coaches, School Board members, and volunteers harmless from any and all liability, actions, causes of action, debts, claims or demands of any kind and nature whatsoever which may arise by or in conjunction with participation, and certify that the student is in good physical health and is capable to participate in the extracurricular activity(ies). We agree to hold the Freeport School District #145, its employees, agents, coaches, School Board members, and volunteers harmless from any and all liability, actions, causes of action, debts, claims or demands of any kind and nature whatsoever which may arise by or in conjunction with participation in the activity(ies). The terms hereof shall serve as a release and assumption of risk for my heirs, estate, executor, administrator, assignees and for all members of my family. I, as the parent, hereby give pre-occurrence consent to the FHN Athletic Trainers. This will permit examination and treatment of my child without the necessity of calling me and possibly delaying treatment. Treatment can include but is not limited to therapeutic modalities (ultrasound and electrical stimulation) and therapeutic exercise (sport specific exercise allowing athlete to return to full participation). These treatment modalities and exercises follow injury rehabilitation protocols and physician’s recommendations as needed. It is our understanding that this examination and treatment of said injury sustained at practice or competition will at that time be free of charge both to the athlete and the school. However, I understand that I will be responsible for the charges for any ongoing or further therapeutic modalities that may be needed or occur at a later time outside practice or competition. Furthermore, I also understand that we have the right to revoke this consent immediately post injury and examination, prior to the provision of any treatment. I also understand that protected health information may be obtained through the completion of this examination and treatment and furthermore authorize the release of such information to the Freeport School District #145. I, as the parent, understand that Freeport School District #145 is providing transportation for my child identified above during the athletic season. In the event that we periodically decide to not have my child use district transportation, I agree to the following items: I voluntarily and knowingly have decided on behalf of the my child identified above that I will assume full responsibility for providing or arranging for the transportation of the student. I agree to hold Freeport School District #145, its Board of Education, Board members, employees and agents harmless in the event of any accident or injury occurring as a result of my decision to decline District-provided transportation to and from the event identified above. I further understand that the District’s liability insurance will not be applicable in the event of any accident or injury suffered by the parent or student identified above as a result of our decision to decline District-provided transportation. I am completely aware of the risks (including, but not limited to, permanent injury or death) inherent in providing or arranging for transportation for my child identified above and accept complete legal responsibility for this decision. Each time a student is released, the parent/guardian will be required to sign out the student with the coach/sponsor prior to leaving. I, as the parent, represent that I have the full legal authority to make the representations set forth above on behalf of my child. If an emergency arises and the parent/guardian is not at the event, permission prior to leaving to the event must be granted in order to permit the student to leave with someone else.
________________________________ Signature Parent/Guardian
_________________ Date Signed
_______________________________ Student Signature
________________ Date Signed
STUDENT SPORT INFORMATION Student Name_________________________________________________
Grade __________________
Student Email________________________________________________
Parent Name:_________________________________________________
Parent Phone Number(s)____________________________________________________________________
Parent Email______________________________________________________________________________
Emergency Contact Name___________________________________________________________________
Emergency Contact Phone Number(s)__________________________________________________________ HEALTH HISTORY/PERMISSION/INSURANCE Kidney Injuries Heart Condition or Heart Disease Epilepsy Diabetes Asthma Hearing Problem While competing do you wear
Glasses Contacts
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Family Doctor Name________________________________________________________________________ Family Doctor Phone Number_________________________________________________________________
Check all sports interesting in participating this school year -Girls’ Basketball Girls’ Bowling Cheer Girls’ Cross Country Dance Girls’ Golf Girls’ Soccer Softball Girls’ Swim Girls’ Tennis Girls’ Track Volleyball
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Baseball Boys’ Basketball Boys’ Bowling Boys’ Cross Country Football Boys’ Golf Boys’ Soccer Boys’ Swim Boys’ Tennis Boys’ Track Wrestling
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