Interscholastic Athletic Permission and Participation Form
PERTH AMBOY CAMPUS
First Name *
Your answer
Last Name *
Your answer
Age *
Your answer
Sex *
Date of Birth *
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Grade *
Campus *
Sport *
Parent/Guardian home phone *
Your answer
Parent/Guardian cell phone *
Your answer
Parent/Guardian Permission To Participate/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 course 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.

School year that my child is covered by under our family insurance policy: *
Your answer
Name of Insurance Policy *
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.
Please check one of the following *
Note: if you use a family doctor, a copy of the required district form must be completed by your Doctor and returned to the School Nurse with his/her findings, recommendations, and any restrictions within 30 days of receipt of this notice.
As a student candidate in the Interscholastic Athletic Program, I will conduct myself in a manner that is beyond reproach and exhibit good sportsmanship and return sports equipment and uniforms issued to me in good condition.
Student Signature: *
Your answer
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