Please be advised that my scholar, First Name* Last Name* has permission to participate in athletic sports and activities at DuBois Integrity Academy. To participate in any athletic activity, a student is required to have a physical examination signed and dated by a physician before any practice, tryout or conditioning.Should emergency medical treatment be necessary during the course of this activity, I Parent First Name* Parent Last Name* , hereby authorize the responsible adult designated in charge of said activity to seek and approve any medical attention needed. I also Please Select have do not have * adequate medical insurance to cover my child in case of athletic injury. Insurance Provider: Insurance Provider* Name of Insured: First Name, Last Name* Policy Number: Policy Number* Furthermore, I hereby release DuBois Integrity Academy and its respective members, officers, employees, and agents from any liability, claims, or responsibility arising out of or in connection with my child's participation in any athletic activity(ies), whether identified above or otherwise. Authorization of TreatmentIn case of an emergency or accident on the school grounds or during any school activity involving my child, First Name* Last Name* which in the opinion of the school authorities present requires immediate medical or surgical attention, I hereby grant permission to said school authorities to obtain the services of a physician or to transport said child to the hospital if it is deemed necessary by school authorities. I herby grant permission, also, to said physician to treat said condition unless I am present and request otherwise or until I later request otherwise.Date* Signature* Phone Number* Street Address* City* State* Zip*