Westlake Middle School Athletic Participation Form - Spring

ALL FIELDS ARE REQUIRED

    Permission to Participate

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    Student Information

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    EMERGENCY MEDICAL TREATMENT INFORMATION

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    Please enter your number in this format ###-###-####
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    Medical History and Update

    The athlete is not cleared to participate until the school physician/school nurse have reviewed and verified the current physical exam and medical records, and have cleared the student for interscholastic athletic participation.

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    Consent for Use of Photographs/Digital Images and Release of Information for Student-Athletes

    I, the parent of the above named student, a student in the Mount Pleasant Central School District, do hereby consent to the release of certain personally-identifiable information pertaining to my son/daughter related to participation in the Mount Pleasant CSD Athletic Program during the 2016-2017 school year. The information may include the student's name, grade, sport(s) of participation, gender, jersey number, height, weight, game, seasonal or team participation statistics, awards received, previous and future institutions of attendance, photographs/digital images or videotapes of students in media print, school newspapers, the District's website or other electronic and broadcast outlets. I am over the age of 18, have read the above information, I understand the information and will be bound by its terms on my own behalf and on behalf of my child. This information will not be released if the School District determines that the information will be used for commercial, solicitation or fundraising purposes.
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    Concussion Management Information

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    ImPACT Testing

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    Transportation Information

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    By printing your name here you agree that you have filled out this form and all of the information above is accurate to the best of your knowledge. By completing this form you hereby certify that you are the parent/legal guardian of the child listed above. By entering your name and selecting “SUBMIT” you acknowledge that among the information provided about yourself or your child may require the submission of what may be considered personal or confidential information, such as your name, your child’s name, medical information, contact information, and other private information. When you submit information to the Mount Pleasant Central School District “MPCSD”, you understand and agree that MPCSD may store your information in a secure manner on its servers. MPCSD will utilize due diligence and prudent efforts to protect such information as would be considered good practice with regard to electronically stored data. MPCSD appreciates the importance of responsible use of this information and will not share it with any third party without express consent by you. If you choose to provide us with information via this form we will use that information only to complete the request specified by that form and to make contact with you with regard to the services on our site for which you have expressed interest.

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    Please hit the submit button ONLY ONCE, then wait for a message confirming your submission before exiting.