***Scholars Academy Athletic Waiver of Liability***
Please print, complete and return this form to the Athletic Director. This form must be completed by the student and his/her parents/guardians and approved by the Athletic Director before a student is allowed to participate in a school sponsored sports program. Please keep in mind this form will kept on file for the school year. If there are any changes in the information provided below, please notify the Athletic Director with the changes immediately.
Student name ______Grade: ______T-Shirt Size:______
*Sport: Fall __ Soccer ___ Cross Country Winter __ JV Basketball
Spring __ Tennis __ Golf
* please indicate which sport(s) the student wishes to pursue; remember all sports have try outs and accepted students may only play one sport per season.
Parent’s or Guardian’s Permission & Waiver of Liability
& Authorization for Emergency Care
I hereby give my consent for the above named student to participate in the Scholars Academy Athletics Program for this school year. I also agree to reimburse the school for any uniforms or equipment issued to my child should it become lost or damaged. I understand that Scholars Academy cannot accept responsibility for personal items or school uniforms lost or stolen.
I authorize the Athletic Director, School Director, Associate Director, Coach or Sponsor in attendance at any Scholars Academy practice, game or activity to select and secure medical attention as may be necessary for my child as a result of injuries or other events requiring emergency care while I/we are not in attendance at such event. I have read and complied with all policies and procedures as outlined in the Scholars Academy Athletics Program Handbook.
I hereby release said school official from any and all liability on account of such selection or authorization for any and all damages which occur on account thereof.
Father/Guardian Signature ______Date ______
Work phone ______Cell phone ______Home phone ______
Address______City ______Zip ______
Mother/Guardian Signature ______Date ______
Work phone ______Cell phone ______Home phone ______
Address______City ______Zip ______
Emergency contact name ______Phone ______
Athlete’s birthdate (mm/dd/yr) ______
Family doctor ______Phone ______
Preferred Hospital ______Phone______
Family Medical Insurance Carrier ______
Group or ID# ______
Family dentist ______Phone ______
Family Dental Insurance Carrier ______
Group or ID# ______
Please list any allergies and/or physical conditions we should be aware of (if medication is needed for any documented medical reason, please provide the medicine with clear instructions on dosage, method of administering, and place all in a clear ziplock bag marked with your child’s name; the marked ziplock bag will be placed in a lockbox under the coach’s care during practices and games when a parent/guardian is not present):
______
Parent/Guardian Understanding
I understand participating in sports can be an extremely valuable experience for young people. The Scholars Academy Athletics Program makes every attempt to recruit experienced, skilled and motivated volunteer coaches and supply our athletes with appropriate equipment. However, athletes are exposed to moving objects, stationary objects, various playing surfaces, transportation and other items that can cause injury and/or death. This communication is being written so you and your athlete can understand that there are potential risks/dangers involved in participation in athletics. By signing this form, I hereby release the Athletic Director, School Director, Associate Director or Coach from any and all liability for injury and/or damages which may occur.
Parent/guardian signature ______Date ______
Scholars Academy Athletics Program
Student-athlete & Family Contract
By signing this contract I, ______agree to abide by the following conditions:
(student-athlete name)
A. Demonstrate appropriate behavior during all team events including, but not limited to, practices, games, socials and tournaments.
B. Compete in the spirit of good sportsmanship, review and follow all the policies and rules set out in the Scholars Academy Athletics Program Handbook.
C. Respect my teammates, coaches, referees, opponents, spectators and other members.
D. Attend all scheduled practices, games and tournaments. In the event of my absence, I will contact the coach to make them aware of my situation.
E. Support the program by participating in athletic fundraising programs.
F. As a student-athlete, I am a student first and must continue to commit to my academics.
I understand that I am responsible for my behavior and actions. Poor sportsmanship and inappropriate behavior will not be tolerated. Failure to comply with the above conditions may result in my suspension or removal from the team.
______
(student-athlete signature) (date)
By signing this contract, I ______agree to:
(parent name)
A. Review this contract with my child before signing.
B. To demonstrate good sportsmanship and follow the policies set out in the Scholars Academy Athletics Program Handbook.
C. Maintain the highest standard of conduct and respect toward all players, coaches, referees, spectators and other members.
D. Provide or arrange timely transportation to and from practices and games.
E. Remember my child is a student first, athlete second. Commitment to academics is the priority.
By signing this contract, I understand that I am responsible for the behavior and actions of myself and all other members of our family. Poor sportsmanship and inappropriate behavior will not be tolerated.
______
(parent signature) (date)
This form must be completed and returned with the medical liability waiver form and physical exam verification form.