C.Y.A.A. Sports Permission and Emergency Form

Saint Francis Xavier
Sport(s):
I/We, the parent(s)/guardian(s) of (please insert name below) request that SFX allow my child to participate in the C.Y.A.A. after school sports program.

We hereby release and save harmless SFX or any and all its employees from any and all liability for any harm arising to my/our son/daughter as a result of participating in the C.Y.A.A. after school sports.

Be it known that, I, the undersigned parent or guardian of the student above-named, do hereby give and grant unto any medical or hospital my consent and authorization to render such aid, treatment, or care to said student, as in the judgement of said doctor or hospital, may be required on an emergency basis, in the event said student should be injured or stricken ill while participating in an interscholastic activity.
Student's Name Student's Name First Last
Date Date / MM / DD YYYY
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
In case of emergency, please contact:
Name Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Mother's Phone Mother's Phone - ### - ### ####
Father's Phone Father's Phone - ### - ### ####
Family Physician
Physician's Phone Physician's Phone - ### - ### ####
*In case of an accident, may we choose a physician?

*In case of an accident, may we choose a physician? Yes No
Hospital Preference
Insurance Company
Policy/Group #
All students must have a valid doctor's physical (good for one year) on file with the school or attached to this form on the first day of practice.

All students must have a valid doctor's physical (good for one year) on file with the school or attached to this form on the first day of practice. Physical is attached to this form If not done yet, physical will be turned in BEFORE practices start to Athletic Director, Angie Vecchiarelli
Physical Form Upload (If you have physical completed, please upload here)

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Text

C.Y.A.A. Sports Permission and Emergency Form

C.Y.A.A. Sports Permission and Emergency Form

I/We, the parent(s)/guardian(s) of (please insert name below) request that SFX allow my child to participate in the C.Y.A.A. after school sports program.

In case of emergency, please contact: