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GHS 2015-2016 - Student Participation, Emergency Contact Info and Parental Approval Form
This electronic form will take place of the "Green Card" and information will be shared with your child's coach each season throughout the school year. All information should be accurate and kept up to date. Please fill out a new form if any of your child's information changes.
This form must be filled out completely and filed coach before a student will be allowed to practice or to compete in interscholastic athletics at Greely High School or Greely Middle School. In addition to this form, any individual teams may have other specific requirements and/or paperwork for their prospective athletes.
All interscholastic athletic participants are required to have an in-force, accident-coverage, insurance program prior to the onset of their sports season and continuing throughout the sports season. MSAD51 does offer a Student Insurance plan.
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* Indicates required question
Student Last Name
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Your answer
Student First Name
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Your answer
Grade (class of)
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Class of 2016
Class of 2017
Class of 2018
Class of 2019
Parent Name(s)
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Your answer
Parent Email(s)
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Your answer
Home Phone Number
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Your answer
Parent 1 Cell Number
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Your answer
Parent 2 Cell Number
*
Your answer
Emergency Information: In case of Emergency and Parents cannot be reached, please contact:
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Your answer
Emergency Contact Phone Number (home and cell if applicable):
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Your answer
If there are any Physical or Medical Conditions that the school district/coach should be aware of, please explain below:
i.e. Asthma, Diabetes, Allergies, Concussion History, etc.
Your answer
Since the student last had a physical exam: Student has had injuries requiring medical attention?
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Yes
No
Student is now under a physician's care or takes medication?
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Yes
No
Has the student suffered a concussion?
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Yes
No
If applicable, please discuss student concussion history
i.e. Number of concussion(s), date of concussion(s) and severity
Your answer
Since the student last had a physical exam: Student has had a surgical operation or been hospitalized?
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Yes
No
Student wears glasses or contacts?
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Yes
No
Please explain any "yes" answers to the above questions:
Your answer
Student Birthdate
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Your answer
Student Address:
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Street & Town
Your answer
Name of Insurance Company:
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Your answer
Insurance Company Policy Number
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Your answer
Name of Student's Physician:
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Your answer
Physician Phone Number:
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Your answer
Preferred Hospital
*
Your answer
Greely High School and Greely Middle School Athletics: This application to compete in interscholastic athletics for the before named school is entirely voluntary on my part and is made with the understanding that I have not violated any of the eligibility rules and regulations of the Maine Principals’ Association. I will abide by all Greely High School and Greely Middle School eligibility policies and training rules. My child and I fully understand the district policies regarding athletics.
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Please check box for your child to agree to the above
Yes, My child agrees to the above statement
Required
Greely High School and Greely Middle School Athletics: I hereby give my consent for the above named student: (1) to represent his/her school in athletic activities, provided that such athletic activities are approved by the MSAD 51 Board of Directors; (2) to accompany any school team of which he/she is a member on any of its local out-of-town trips. I authorize the school to obtain, through a physician of its own choice, any emergency medical care that may become reasonably necessary for the student in the course of such athletic activities or such travel; (3) to have a physical examination by a physician.”
*
Please check box to agree to the above
Yes
Required
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