Office of Catholic Schools-Diocese of Madison

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ALTERNATE YEAR ATHLETIC PERMIT CARDS

 

*Student Athlete Name:
*Grade:	*Age:	*Sex:
*Date of Birth: *Place (County/State):

 

I hereby give my permission for the above student to compete and represent his/her school in sports. I further agree to be financially responsible for the safe return of all athletic equipment issued to him-her).

 

I also attest to the fact that the above named student has not been hospitalized or suffered any serious illness or injury since the time of his/her last physical examination. If the above has suffered any of the above or has been hospitalized for any reason since the date of his/her examination - PLEASE DO NOT SIGN THIS CARD. THIS STUDENT MUST BE RE-EXAMINED - another examination card should be obtained from the school.

 

PARENT: If you are unsure of the seriousness of illness or injury, consult with your family doctor.

 

*Signature of Parent/Guardian:		*Date:
Typing your name in this box indicates your electronic signature.
*Email:

 

ALL BOYS AND GIRLS PARTICIPATING IN INTERSCHOLASTIC ATHLETICS MUST HAVE THIS CARD ON FILE AT THEIR SCHOOL PRIOR TO PRACTICE AND/OR PARTICIPATION.

 

 

Download a PDF version of this form to sign and turn in to the school office.