Intramural Dodgeball Tournament / Student Information

MAHONE MIDDLE SCHOOL

Name: ______Gender: ___ Birth Date: ____/____/_____ Age: ___ Grade: ___

Address: ______City: ______Phone #: ______

Mother/Father/Guardian’s Name: ______Phone #: ______

Hospital Preference: ______

Emergency Room Preference: ______

Medical Insurance Carrier: ______

Student’s Health Problems: ______

Who Will be Providing Transportation for this Student? ______

*** The above information must be filled out completely before any students are allowed to participate.

SPORTSMANSHIP STATEMENT

In order to encourage proper conduct before, during and after all scheduled contests; officials, supervisors and administrative personnel will make decisions on whether to warn, penalize or eject players, teams and/or fans for unsportsmanlike conduct.

Participants and spectators who choose to practice unsportsmanlike behavior at any time during this event will be ejected from the contest. The ejection may be administered by an event contest official or supervisor and without refund or reimbursement of admission and/or fees. Examples of unsportsmanlike conduct include but are not limited to: swearing, vulgar or abusive language, unnecessary roughness, excessive technical fouls, flagrant actions towards an opponent, flagrant actions toward an official, fighting or inciting a fight and inappropriate comments or actions.

Any individual ejected from the contest as a result of unsportsmanlike conduct is automatically suspended from the contest and if necessary will be asked to leave the premises. The team captain is responsible for the actions of any player on his/her team and for spectators directly identifiable to his/her team. The conduct of all players and spectators before and after the game is as important as conduct during the game.

I have read the Sportsmanship Statement and I understand the policies and procedures of the Sportsmanship Statement. I certify that this has been discussed with the members of the team and we will abide by the Sportsmanship Statement.

Athlete Signature: ______Date: _____/_____/______

We/I the parent(s) or guardian do hereby acknowledge that we/I fully understand the possibility of the risk of serious injury involved in athletic participation and do hereby grant our student permission to participate in intramural sports. We/I also agree to monitor our student athlete’s health and report any change of health condition to the coach. We/I also grant the coach permission to take reasonable medical steps including the calling of an ambulance to convey him / her to a hospital in case of serious injury.

Parent/Guardians’ Signature: ______Date: _____/_____/______