Mt. Vernon Township High School

MT. VERNON TOWNSHIP HIGH SCHOOL

Mt. Vernon, IL

Dear Parent/Guardian:

We are pleased that your son/daughter is one of the many students who will participate in our high school athletic program this year. We trust that the experience will be of great value. All student athletes must have a yearly physical examination before they can participate or try out in any extra-curricular activity.

Mt. Vernon High School has Student Accident Insurance with Gerber Life Insurance Company. This plan is secondary to any primary insurance the student may currently have. An accident form will be available in the Athletic office or the Nurses office. The student’s parent or guardian is responsible for completing and submitting the information to Administrative Concepts, Inc. Mt. Vernon Township High School is not responsible for filing insurance claims. I want to emphasize that any medical bills not paid by the insurance company are the responsibility of the parents, not Mt. Vernon High School.

Again, we trust that participation in athletics at Mt. Vernon High School will be a rewarding experience for your child.

Sincerely,

Doug Creel, Athletic Director

PRINT STUDENT’S NAME: ______

I (do - do not) have insurance which can be used as primary coverage and will file the initial claim with that company.

My (son - daughter) (has - has not) had any serious illness or injuries in the past year. My (son - daughter) (has - does not have)

my permission to participate in interscholastic sports at Mt. Vernon Township High School.

PARENT/GUARDIAN SIGNATURE:______DATE: ______

ATHLETE NAME: ______BIRTHDATE: ______GRADE: 9 10 11 12

ATHLETE CELL #:______SCHOOL ID# ______

HOME ADDRESS:______TOWN:______ZIP:______

PARENT/GUARDIAN #1: ______RELATIONSHIP:______

CELL #: ______WORK #:______HOME #:______

PARENT/GUARDIAN #2: ______RELATIONSHIP:______

CELL #: ______WORK #:______HOME #:______

ADDITIONAL EMERGENCY CONTACT: ______RELATIONSHIP:______

CELL #: ______WORK #:______HOME #:______

FAMILY DR.:______DR. PHONE #:______HOSPITAL:______

DOES THE ATHLETE HAVE ANY OF THE FOLLOWING CONDITIONS (PAST OR PRESENT)?

ALLERGY if yes, please specify ______ASTHMAif yes, do they use an inhaler? YES/NO DIABETES SEIZURES HEART CONDITION CONCUSSION if yes, when was last one? ______

OTHER ______

Emergency Authorization: With this signature, I give permission for the treatment of injuries or illness to the above noted athlete and respect any decisions based on fact of injury to transport to a medical facility for further care by a licensed physician, and with such detail release the Orthopaedic Center of Southern Illinois, the assigned Certified Athletic Trainer, Mt. Vernon Township High School and responsible school personnel of liability as long as reasonable and prudent care has been administered to the best of their knowledge in assistance with the above noted athlete.

PARENT/GUARDIAN SIGNATURE:______DATE: ______