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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:                                                    


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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