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Participant’s
Name:
Date of Birth:
I
believe that
is
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.
Parent/Guardian’s
Signature:
Date:
In the
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.
Home
Phone:
Work Phone:
Address:
City:
State:
Zip:
Person
to be notified other than parent or guardian in an emergency:
Name:
Phone:
Physician’s
Name:
Phone:
Insurance
Company:
Policy
Number:
Parent/Guardian’s
Signature:
Date:
Medical
Information
Circle
One
Circle
One
Heart
condition or disease
Yes
No
Asthma
Yes
No
Diabetes
Yes
No
Allergic to medication
Yes
No
Convulsions
disorder
Yes
No
Allergic to insect stings
Yes
No
State
allergies:
Additional
medical information that may be helpful and medication currently
receiving:
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medical.pdf
