ButtsCountySchools

ParentConsent/AthleticRelease

NameSportM_FDate

HomePhone

Grade

Birthdate

Address

NameofParent/Guardian

Address(ifdifferentfromabove)

Mother’scell

Father’scell

Mother’sBusinessFather’sBusiness

PersonotherthanParentorGuardiantoContactincaseofEmergency

NameRelationPhone

Address

Student’sPhysicianName_Office#

InsuranceCompanyNamePolicy#

WARNING: Althoughparticipationinsupervisedinterscholasticathleticsmaybeoneoftheleast hazardousin whichstudentswillengageinoroutofschool,byitsnatureparticipationininterscholastic athleticsincludesariskofinjurywhichmayrangein severityfromminortolongtermcatastrophic. Althoughseriousinjuriesarenotcommoninsupervisedschoolathleticprograms,itis possibleonlyto minimize,noteliminate,therisk.

Participateshavetheresponsibilitytohelpreducetheriskofinjury.Playersmustobeyallsafetyrules, reportallphysicalproblemstotheircoaches,followaproperconditioningprogram,andinspecttheir equipmentdaily.

Bysigningthisreleaseform,youacknowledgethatyouhavereadandunderstandthiswarning.Parents orstudentswhodonotwishtoaccepttherisksdescribedinthiswarningshouldnotsignthisrelease form.

I(we)herebygiveconsentfor ______(Student’s name)to:

(1) Competeininterscholasticathleticsin GeorgiaHighschoolAssociation(GHSA)sports,

exceptthoseCROSSEDOUTbelow:

Baseball / CrossCountry / Soccer / Track& Field
Basketball / Football / Softball / Volleyball
Cheerleading / Golf / Tennis / Wrestling

PARENTS, PLEASEINITIALEACHOFTHEFOLLOWINGSTATEMENTSTOSHOWTHATTHESTATEMENTHASBEENREAD,UNDERSTOOD,ANDAPPROVED.

I consent to havemyson/daughterrepresenthis/herschool in approved activities exceptthoseexcluded by the examining physician.

Igrantpermissionfor mychildto accompanyanyschool teamof whichhe/she isa memberto out‐of‐town trips.The athletewill be transported to and fromall school eventsin schoolapproved vehicles.Parentswishingto havetheir child

with themwhenreturning froman eventmustmakethearrangementswith thecoach.

Inthe eventof anemergencyrequiringmedical attention,I expecteveryreasonableattemptto bemadeto contact me. In caseI cannotbereached,I grantpermission for any immediatetreatmentdeemednecessaryby theattendingphysician and transferofmychildto a qualifiedmedical facility.Thisauthorization does not covermajor surgeryunless formallydecreed prior to surgeryby two licensedphysiciansordentists. I releasefromliability theButts County Board of Education and school administratorsorresponsiblepartyexercisingresponsibleauthority.Iwill beresponsiblefor hospital orphysician

chargesmade during theexerciseof theauthority.

Iagreenot to holdtheschool oranyone acting on itsbehalfresponsiblefor any injuryoccurringto mychild in the propercourseof such athletic activitiesortravels.

Iacknowledgethat organized school activities involvesthepotential for injurywhich isinherent in all sports.I

acknowledgethat evenwith thebest coaching, useof advancedprotectiveequipmentandstrictobservanceof rules,injuries arestill a possibility. On rareoccasions,thesecan besosevereasto result in total disability, paralysis,orevendeath.

_IherebygrantButts County Schoolspermissionto releasescholastic and personal informationabout meto any interestededucational institutionsorbranches ofthearmedforces.

Date

SignatureofParentorGuardian

SignatureofStudentAthlete