ORRJHS Intramurals Permission Form
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Student Number *
Student Last Name *
Student First Name *
Address *
Town *
State *
Zip Code *
Parent/Guardian Legal Name *
Parent/Guardian Home Phone Number *
Parent/Guardian Cell Phone Number
Parent/Guardian Email Address
Sports Offered
Please check all that your child might participate in.
Participation Information
1. Permission Slip: Needed for students participating in either Interscholastic Sports and Intramural activities.

2. Concussion Form: Needed for students participating in Interscholastic Sports.

3. Insurance is required for participation in Interscholastic sports only: Track and X-Country. Not for Intramurals.
All students must have purchased the School Insurance Plan or provide the school with verification of their family health insurance coverage. A copy of your insurance card noting insurance company, policy number, and expiration date.

4. Physical Exams: All student-athletes participating on Track or X-Country Teams only team must have a valid
physical exam. Not needed for intramurals. Exams are valid for thirteen (13) months.

5. Cost: $25.00 annual Intramural fee which will cover all Intramural activities for the school year.

$50.00 fee per sport for Interscholastic Sports: Track and X-Country.
Example: The cost is $50 for X-Country Team and another $50 for Track Team.
Please make checks payable to: “Old Rochester Regional School District”

Late Buses: Tuesdays, Wednesday, and Thursdays at 3:30 PM. Personal transportation is needed on other days.

Return Paperwork: Track and X-Country Teams return all forms to Coach Caron

All Intramural forms return to Mr. Jancaterino in the Gymnasium.

The permission slip covers all activities and only needs to be completed once per year.
Signature Block *
My child has my permission to participate in all of the above listed activities involved with the Old Rochester Junior High SchoolInterscholastic/Intramural programs. I understand that athletic away contests involve student-athletes traveling by bus. In addition, I hereby give permission to staff to seek appropriate medical attention if I cannot be contacted.
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