Athletic Permit Form
Complete the following form if your child is signed up to participate in athletics this year at Richmond. If you have multiple children participating, please fill out each form twice.
Child Information
Select the sport (or sports) your child is participating in this season. *
Required
Child First and Last Name *
Your answer
Grade *
Required
Parent/Guardian Information
Name of Person with Legal Custody *
Your answer
Relationship to child *
Your answer
Mother's name and phone number *
Your answer
Father's name and phone number *
Your answer
Emergency contact name and phone number *
Your answer
Medical Information
My child has a medical condition that the coach/activity supervisor should be aware of. *
If yes, please explain/indicate any procedures necessary to stabilize the condition until professional medical help can be obtained if your child were to become ill while participating.
Your answer
Is your child prescribed any form of medication that must be taken while participating in an off-campus activity or event? *
If yes, please list the name of the medication(s), dose/frequency, and possible side effects.
Your answer
Ordering physician's name and phone number.
Your answer
Does your child have allergies? *
If yes, please describe allergy types and typical reactions.
Your answer
Does your child have any physical restrictions? *
Insurance company and phone number *
Your answer
Acknowledgment
By checking below I hereby give permission for the above student to practice, compete, and represent the school in approved interscholastic sports excepting those restricted on this form and as parent (or legal guardian) of the above named student state that: a.) Coaching/Activity staff may be informed about your child's health concern in order to provide safe, appropriate care for your child, b.) I grant permission for my son/daughter, named above, to be given immediate emergency care in case of injury as the result of athletic competition. c.) My insurance company covers my son/daughter for all extra-curricular activities. *
Required
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