GERONIMO STUDENT-ATHLETE & ACTIVITY INFORMATION
Email address *
STUDENT NAME *
STUDENT GRADE *
Required
PARENT/GUARDIAN NAME *
PARENT/GUARDIAN PHONE NUMBER *
In compliance with Oklahoma Statute Section 24-155 of Title 70, this acknowledgement form is to confirm that you have read and understand the CONCUSSION FACT SHEET related to potential concussions and head injuries occurring during participation in athletics. I, as a student-athlete who participates in athletics and I, as the parent/legal guardian, have read the information material provided to us by Geronimo Public Schools related to concussions and head injuries occurring during participation in athletic programs and understand the content and warnings. *
CONCUSSION AND HEAD INJURY ACKNOWLEDGEMENT
Required
I give my son/daughter permission to leave school early (during athletic period) with the understanding that students are not allowed to go into any part of the school during that period. *
EARLY RELEASE
Required
Pupil Agreement: While participating in this and other school activities, I will accept responsibility for maintaining good conduct and I will follow directions of coaches or sponsors at all times. *
GOOD CONDUCT STATEMENT
Required
Parent/Guardian Permission: I give permission for my student to participate in this and other future school activities and trips that may be scheduled by coaches or sponsors. I understand the school will provide supervision for trips. I also understand that no special insurance is provided by the School Board; however, the insurance required of athletics and the school-time accident insurance taken by many pupils will apply to this activity. I hereby give consent for medical treatment deemed necessary by physicians designated by school authorities and/or for transportation to a hospital emergency room or treatment for any illness or injury resulting from his/her athletic participation. I understand that an attempt will be made to contact me in the most expeditious way possible. If unable to communicate with me, the treatment necessary for the best interest of the above named student may be given. In the event that emergency arises during a practice session, an effort will be made to contact the parents or guardian as soon as possible. Permission is also granted to the coaching staff to provide the needed emergency treatment to the athlete prior to his/her admission to the medical facilities. *
Required
FAMILY PHYSICIAN CONTACT INFORMATION
Physician Name *
Physician Phone Number *
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