MIDDLEBOROUGHPUBLICSCHOOLS
PARENTALPERMISSION, RELEASEANDINDEMNIFICATIONAGREEMENT
I, the undersigned student aged 18 or over, or the undersigned parent or lawful guardian of ______, a minor, do hereby consent to theparticipation of (name of student)______in the (event/sport etc.) program offered by the John T. Nichols Middle School.
I/we understand that participation in the event/sport is not required and that participation is voluntary.
I/we have read and understood the information provided by the school that explains that the program or event, including the training of participants, the eligibility and safety rules, any equipment to be used, the medical insurance requirements and the school’s emergency medical plan. I/we have had an opportunity to ask questions, and have had all of my/our questions adequately answered by school staff.
I/we have read the information on concussions and understand the serious nature of such injuries. To aid Middleboro Middle school in compliance with Massachusetts General Laws governing the safety regulations for school extracurricular programs (which makes annual training for parents and athletes mandatory), I/we have read and understand “Heads Up Concussion in school sports” fact sheet and/or completed the free online training on concussions at Further, I/we have provided all past medical concussion history including date(s) of injury, and date(s) of medical clearance to return to activity by a medical doctor below:
Date(s) of ConcussionDate(s) of Medical Clearance to return to activity
______
______
______
I/we Understand the activities of this program or event, its rules and requirements and its potential risks. I/we accept these conditions and hereby grant permission for my/our child’s participation. I/we hereby forever release the Town of Middleboro and its officers, employees, agents, and volunteers from any and all claims for damages with respect to or in connection with all known and unknown personal injuries incurred by my/our child while participating in the program or event except for damages caused solely by the negligence of th Town of Middlebor, the Town of Middleboro School Department or its Officers, employees, agents, or volunteers.
Witness the hand(s) and seal(s) of the undersigned this ______day of ______, ______.
Student’s Name: ______
Parent/Guardian Signature: ______
Parent/Guardian Signature: ______
Signature of student age 18 or over: ______
For emergency purpose, would you please fill in the form below:
Athletic Sport ______
Parent Name ______
Parent Home phone or cell ______
Emergency Contact______
Emergency Telephone______
The following Intramural Sports will be played during the 2016-2017 season:
SportSeasonCost
Flag FootballFall$25.00
Basketball Winter$25.00
Floor HockeyWinter$25.00
Capture the FlagSpring$25.00
Money Order made out to: Middleborough Athletics
Before a student may participate, this parental permission/doctor’s approval form must be filled out completely and returned to the Physical Education Teachers or Coaches.
A new form is needed each year. Only one form needs to be completed for all activities for the entire year.
At the beginning of each new intramural, sign ups are held for 1 week in the cafeteria, after which teams are picked and posted in the cafeteria. Teams play 2x per week when possible.
Middleboro Public Schools Parent Permission, Release and Indemnification Agreement.
My/Our child wishes to participate in the Middleborough Public Schools Intramural program. I/we understand that participation in the program or event is not required and participation is voluntary.
I/We have read and understand the information provided by the school that explains that program or event. I/We understand that my/our signature(s) below may be used as permission for release consent during medical emergencies.
I/WE understand activities of this program or event, its rules and requirements and its potential risks. I/We accept these conditions and hereby grant permission for my/our child’s participation. I/We hereby release the Town of Middleborough, the Town of Middleborough School Department and its officers, employees, agents and volunteers from any and all claims for damages with respect to or in connection with personal injuries incurred by my/our child while participating in the program or event except for damages caused by the sole negligence of the Town of Middleborough, the Town of Middleborough School Department or its officers, employees, agents or volunteers. I/We hereby agree to indemnify and hold harmless the Town of Middleborough, the Town of Middleborough School Department and its officers, employees, agents and volunteers with respect to any such claims for damages, which are not caused by the sole negligence of the Town of Middleborough, the Town of Middleborough School Department or its officers, employees, agents or volunteers.
Date: ______
Student Name(Print):______
Address:______
Date of Birth: ______
Parent(s)/Guardian(s) Signature:______
Home Tel. #______
Emergency Contact: ______
Telephone # ______
INSURANCE
Athlete: ______Date: ______
Address: ______
Telephone: ______
All students participating in an intramural activity must be covered by an injury insurance plan. Students failing to provide documentation of appropriate insurance coverage will be denied the opportunity to participate as part of the Middleborough School’s Intramural Program. Students must be covered either by school insurance or under their own family insurance plan.
Please Check Type of Coverage
______A. Purchase of student insurance and/or
______B. Personal insurance provided by parent or other source.
If “A” is checked, please place signature below. The completed form must be returned to your coach before participating in any aspect of the intramural program.
If “B” is checked, please complete the following:
Name of Ins. Company______
Effective Date of Plan ______
Parent’s Signature:______
I Hereby certify that the above listed insurance is in force and further that such insurance will cover medical needs and injuries associated with participation in an intramural program.
PHYSICAL EXAMINATION
Physical exams are required to participate in the Middleboro Public Schools intramural program. This form must be signed and dated by a physician. Exams are valid for one calendar year.
DATE OF LAST PHYSICAL: ______
This certifies that ______was examined by me and found able to participate in intramural sports activities without restrictions.
DR’S SIGNATURE OR STAMP BELOW:
______
JOHN T. NICHOLS, JR.
MIDDLE SCHOOL
ACTIVITIES
2016-2017
INTRAMURALS
A $25.00 money order only made out to: MIDDLEBOROUGH ATHLETICS