Athletic Repeater Form
Perth Amboy Campus
Interscholastic Athletic Repeater Form
Please fill this out if you have already submitted the Interscholastic Athletic Permission & Participation Form for a different sport this school year.
First Name *
Your answer
Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Grade *
Sport *
Parent/Guardian Home Phone
Your answer
Parent/Guardian Work Phone
Your answer
Parent/Guardian Cell Phone *
Your answer
Parent's/Guardian's Permission to Participate/To Obtain Emergency Care
I hereby give my consent for my son/daughter to participate in the district's Interscholastic Athletic Program at local or out-of-town games. I am also advised that students must return equipment/uniforms in good condition. Parents/Guardians will be expected to reimburse the district for equipment/uniforms that are damaged or lost

I authorize school personnel to obtain emergency medical care that may become necessary for my son/daughter in the coarse of athletic activities or related travel.

I am also advised that Sports Insurance is provided under what is known as a Full Excess Plan. Parents/Guardians must provide payment from their own personal or group insurance policy for medical expenses or hospitalization. If charges are not covered by the parent's/guardian's personal plan, district insurance will cover the player up to the limits of the district's policy for medical expenses or hospitalization.

Please complete the following pertinent health information assuring that your child's coach will be aware of this necessary and potential lifesaving information. Does your child have:
Asthma *
If yes does your child require inhaler
Allergy that requires the use of an Epi-Pen *
If yes - list allergies
Your answer
Diabetes *
Seizures requiring the use of emergency medication *
If yes - name medication
Your answer
Cardiac history that is pertinent *
If yes - explain
Your answer
School year that my child is covered by under our family insurance policy *
Your answer
Name of Insurance Company *
Your answer
Policy # *
Your answer
Date of last Tetanus Toxoid Booster *
Your answer
I certify that the information provided herein is accurate as of the date of these signatures
Type name for electronic signature
Parent/Guardian Signature
Your answer
New Jersey State Law requires that all students who participate in interscholastic sports receive a physical exam prior to participating in any practice or game. This physical exam may be provided by your family physician or the school physician. If a parent/guardian does not have a home physician, an examination by the school physician may be requested.
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