Date of Birth:
physically capable and able to fulfill requirements needed to be a
Quincy High School Cheerleader.
I understand that this form legally releases all
obligations and responsibilities for the medical treatment of my
son/daughter in the event of illness or injury during any squad
related activities, to the QHS Cheerleading coaching staff when
his/her parent (s) cannot be reached.
I also understand that the Quincy Public School System
requires a physical examination by September 1 of each school year
and that documentation of this examination is necessary.
If there is any physical or medical reason why he/she
should not participate fully, the QHS Cheerleading program
requires a doctor’s release.
Furthermore, the QHS Cheerleading program is not liable for
any injury incurred during any squad activities.
event of an emergency occurring while my son/daughter is
practicing, cheerleading at a game, competing, or on a game or
competition road trip, I grant to the QHS Cheerleading coaching
staff to take whatever action necessary.
In the event that I cannot be reached, I hereby
authorize the QHS Cheerleading coaching staff to
give consent for my son/daughter,
, to receive medical treatment.
to be notified other than parent or guardian in an emergency:
condition or disease
Allergic to medication
Allergic to insect stings
medical information that may be helpful and medication currently