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2022 Winter Sports Sign-Up and Emergency Medical Form
Purpose: To enable parents and guardians to authorize the provision of emergency treatments of children who become ILL or INJURED during extra curricular sports while under school authority, when parents or guardians cannot be reached.
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Sport *
My student attends the following high school: *
Student Last Name *
Student First Name *
Grade *
Parent/Guardian 1 *
Parent/Guardian Phone Number 1 *
Parent/Guardian  2
Parent/Guardian Phone Number 2
Emergency Contact Name *
Emergency Contact Number *
In the event where Parent/Guardian/Emergency contact cannot be reached, please list a preferred physician for your student: *
Preferred Hospital *
In the event where Parent/Guardian/Emergency contact cannot be reached, please list a preferred dentist and dental clinic for your student: *
Does your child have any concerning medical conditions or history that we should be aware of? *
Are there any medications that your child takes or needs with them? *
Consent Agreement
Please check Yes or No for your consent.  By choosing no, your child will not give school authorities to take action in the event of a medical emergency treatment of your child.
*
Required
Participation fee is $50. Please send payments to the Goodridge or Grygla School prior to the first day of practice.
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