Please be advised that my scholar, * * 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 * * , hereby authorize the responsible adult designated in charge of said activity to seek and approve any medical attention needed.
I also * adequate medical insurance to cover my child in case of athletic injury.
Insurance Provider: *
Name of Insured: *
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 Treatment
In case of an emergency or accident on the school grounds or during any school activity involving my child, * * 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.
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