NORTH FLORIDA XPRESS ATHLETE PARTICIPATION AGREEMENT

I. STUDENT-ATHLETE & PARENTAL INFORMATION

(winter/fall)

1. Athlete's Name

2. Athlete's Date of Birth

Date

Age

Grade

3. Name of Parent/Guardian(s)

4. Address of Parent(s)

5. mother Phone Number

Please enter a valid phone number.

5. father Phone Number

Please enter a valid phone number.

II. EMERGENCY CONTACT INFORMATION

1. List two Emergency Contact other than those listed above

(Name) (Relationship) (Home Phone) (Work Phone)

(Name) (Relationship) (Home Phone) (Work Phone) 2. Presently under the following medical treatment or medication:

3. Presently allergic to the following medication

4. Presently wear glasses?

Contact lenses?

5. Describe any other physical limitations or problems that should be known by the coach or Emergency medical personnel (e.g. hearing and vision problems, hemophilia, diabetes, etc:

III. MEDICAL TREATMENT CONSENT FOR

Thereby authorize the coach for NFX, to seek emergency care to the above named student-athlete, to render any treatment or medical or surgical care that they deem necessary to protect his or her health and well-being, and to arrange for any consultation by medical specialists, including surgeons, which they deem necessary to insure the proper care and treatment of any injury. I hereby grant permission to any qualified physician to furnish emergency medical care and treatment under the guidelines specified above. also hereby authorize hospitalization at an accredited hospital if deemed reasonably necessary to provide the proper care or and treatment of any injury sustained by the above named student-athlete.

IV. ATHLETIC RESPONSIBILITY ACKNOWLEDGMENT

The North Florida Xpress staff is dedicated to providing each student with the best possible interscholastic athletic experience. In order to achieve that goal, each student is expected to assume his/her responsibility by adhering to the policies and procedures of NFX.

(Name of Student Athlete)

Hospital Preference

Doctor

Signature of Parent/Guardian

Date

The following serves as NFX policies and procedures including, but not limited to

1. Athletes are responsible for all athletic equipment issued to them throughout the season, and will return such equipment at the conclusion of the season, or will pay the current replacement cost for any of the equipment not returned at the end of that sport season. 2. Athletes are exposing themselves to the risk of injury including but not limited to, the risk of sprains, fractures and or permanent, partial or complete impairment in the use of limbs, brain damage, paralysis; or even death. Having been so cautioned and warned, it is still our desire to participate in sports and to do so with full knowledge and understanding of the risk of injury. Please sign below and turn in along with other required paperwork prior to the beginning of the sports season. If you have any questions, please contact the Athletic Director, Tennille Campbell. We (student and parent/guardian) have read the RTCA Student-Athlete Handbook this school year and thereby have been informed of the program's rules, policies, procedures, and

Parent Name

Parent Signature