Saint Rose High School
Athletic Department
607 7th Avenue
Belmar, New Jersey 07719
Phone: 732-681-1021 Fax:732-681-0157
Agreement to participate in a Spring Interscholastic Sport
Name: ______Grade: _____ Homeroom ______
Transfer Student: _____ Yes _____ No
Office Use: Date of Physical:______Date Cleared:______
BASEBALL – GOLF – lAcROSSE – SOFTBALL – TENNIS - TRACK
I realize that the above sports are vigorous physical activities which sometimes involve:
- Violent body contact, strenuous exertion, rapid directional changes, inadvertent physical contact
I understand that participation in the above sports involves certain inherent risks and that regardless of the precautions taken by ST. ROSE HIGH SCHOOL or the participants, some injuries may occur. These injuries might include, but are not limited to:
-Knee injuries, broken bones, sprained ankles, concussion, back injuries, quadriplegia, death
These injuries may result from hazards such as:
-Heading the ball, uneven playing surfaces, contacting goal posts or other solid objects, being struck by golf/tennis balls, violent bodily contact, strain or exertion
The likelihood of such injuries may be lessened by adhering to the following safety rules:
-Being in good physical condition, obeying and paying strict attention to the training rules, reporting any physical hazards to the coach
In order to properly protect my own safety and that of my fellow participants, I agree to follow these rules as well as any others that may be given by my coaches. Further, in recognition of the importance of shared responsibility for safety, I agree to report any noted deviations from the safety rules as well as any observed hazardous conditions or equipment to my coaches.
I further certify that my present level of physical condition is consistent with the demands of active participation in any of the above sports.
PARENTS PERMISSION
NAME______Grade ______
Requests enrollment on the ______team. I have complied with all eligibility requirements and have obtained the necessary insurance. I understand that I am responsible for all items of equipment issued to me and that I will pay for all items lost, stolen or misplaced.
Date ______Parent Signature______
I have read and understand the information on Sudden Cardiac Death , Concussion and Consent to Steroid Testing that is posted on the SRHS Athletic Website Forms Page.
Date______StudentSignature______
Date______ParentSignature______
The following is a list of all my known health conditions which might affect my ability to participate: ______
I have carefully read the foregoing document. I have had the opportunity to ask questions
and have them answered. I am confident that I fully know, understand and appreciate the
risks involved in active participation in ______and I am voluntarily requesting
permission to participate.
Student Signature: ______Date:______
Parent Signature: ______Date:______
Grade: ______Homeroom: ______
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Please complete the following information for our records:
Last Name: ______First Name: ______
Address: ______Town: ______Zip______
Email Address: ______
Public School District: ______
Phone: ______Sex: M or F (circle one)
Date of Birth: ______Age: ______
Father's Name:______Phone: ______
Mother's Name: ______Phone: ______
City and State where you were born: ______
Date you entered St. Rose High School: ______
Did you transfer from another high school to St. Rose HS?______
If so, which high school? ______
Important Notice: If you have transferred from another high school in the past year, you are required to file a transfer waiver form with the NJSIAA. You may NOT compete in a game or scrimmage until these forms have been processed. Pick up these forms at the Athletic Director’s office as soon as possible.