The Montclair Kimberley Academy

Montclair Kimberley Academy Parent Permission Form

Department of Athletics

Student Name: Grade: (circle one) 9 10 11 12

In consideration of the benefit which my son/daughter will derive from this activity, I hereby release The Montclair Kimberley Academy, its trustees, teachers, staff, parents, and any other individuals associated with this activity, from any and all claims or actions whatsoever in connection with the transportation, operation and supervision of this activity. I understand that injuries may occur in interscholastic sports training and competition. I give permission for my son/daughter, whose name appears above, to participate in the sport checked below. In the event of an emergency or in case parents/guardians cannot be reached, I give permission for coaches, the nurse and/or trainer to provide first aid treatment and to act on my behalf to approve emergency transportation and/or medical treatment.

Parent’s Signature Date

Student’s Signature Date

Please check ONE sport:

_____ Baseball _____ Boys’ Lacrosse _____ Boys’ Track and Field _____ Boys’ Tennis

_____ Softball _____ Girls’ Lacrosse _____ Girls’ Track and Field _____ Golf

Name of Parent/Guardian

Home Phone Work Phone Cell Phone

Name of Parent/Guardian

Home Phone Work Phone Cell Phone

Person to be contacted in case of emergency when parents cannot be reached:

Name Home Phone Work Phone

Family Doctor Phone