PITT COUNTY SCHOOLS

PARENT PERMISSION

INTERSCHOLASTIC ATHLETES

Name of Parent/Guardian:                       (Please Print)

Student-Athlete Name:            (Please Print)             Student I.D:

Street Address:

School:                                                                          Grade:

City:

State:

Zip Code:

Date of Birth:        

Phone:   Home:

               Work:                                                 

               Cell:

  *Please denote times available at each number             

Request for Permission:  We, the undersigned student and the student’s parent/guardian, apply for permission to participate in interscholastic athletics in the following sports/areas:

[  ] Baseball

[  ] Basketball

[  ] Cheerleading

[  ] Football

[  ] Soccer

[  ] Softball

[  ] Volleyball

[  ] Wrestling

[  ] Student Team Manager

General Requirements:  We have read and discussed the general requirements for middle school athletic eligibility. We understand that additional questions or specific circumstances should be directed to our student’s coach, athletic director or principal.

Risk of Injury:  We acknowledge and understand that there is a risk of injury involved in athletic participation. We understand that the student-athlete will be under the supervision and direction of a PCS athletic coach. We agree to follow the rules of the sport and the instructions of the coach in order to reduce the risk of injury to the student and other athletes. However, we acknowledge and understand that neither the coach nor PCS can eliminate the risk of injury in sports.  Injuries may and do occur. Sports injuries can be severe and in some cases may result in permanent disability or even death. We freely, knowingly, and willfully accept and assume the risk of injury that might occur from participation in athletics.

Release:  In consideration of PCS allowing the student-athlete to participate in athletics, we agree to release and hold PCS, its athletic coaches and other employees free, harmless and indemnified from and against any and all claims, suits or cases of action arising from or out of any injury that the student-athlete may suffer from participation in athletics other than an injury resulting from gross or willful negligence.

Insurance:  Pitt County Schools provides an All-Athletic Insurance policy covered by MEGA Life. This is a secondary insurance policy.  These limited benefits are listed on the back of the Athletic Eligibility Regulations sheet. 

Check one: [  ] School Accident Insurance or [  ] Other
Name of Other Insurance:

Policy Number:

Street Address:

Policy Term From:

                           To:

City:

State:

Zip:

Group Number:

CERTIFICATION AND MEDICAL AUTHORIZATION:  We certify that all of the information provided by us on this form is correct. We agree to abide by state and local rules. We give our consent for the student to receive a medical screening examination prior to participation in athletics. If the student-athlete is injured while participating in athletics and PCS is unable to contact the parent, we grant PCS permission and authority to obtain necessary medical care and/or treatment for the student’s injury. Treatment may include, but is not limited to, first aid, CPR, and medical or surgical treatment recommended by a physician. We accept the financial responsibility for such medical care or treatment. 

Release of Medical Information:

I also give my permission for the treating physician to release information to the athletic trainer/first responder and/or to exchange health-related information needed to care for my child with physicians, coaches, other healthcare providers, etc. throughout the school year.

We, the undersigned student and parent, have read this document and understand and agree to  the expectations for athletic participation at the middle school level.

Student:

Date:

Parent/Guardian:

Date: