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Waiver and Emergency Contact Information

Waiver and Emergency Contact Information

Please complete the form below. Required fields marked with an asterisk *

Contact Information

Athlete First and Last Name*

Answer Required

Student Grade in school*

Answer Required

Student Age*

Answer Required

Student Street Address (physical address only)*

Answer Required

Parent/Guardian First and Last Name*

Answer Required

Parent/Guardian Phone 1*

Number Required

Parent/Guardian Phone 2

Number Required

Emergency Contact Information

Emergency Contact Name*

Answer Required

Emergency Contact Phone*

Number Required

Family Physician*

Answer Required

Physician Phone*

Number Required

Describe any medical or physical conditions, medication information, or allergies which could interfere with the student's safety in extracurricular activities. (Please include food allergies). If none, type N/A. *

Answer Required

I, the parent or guardian of the above named student give my approval to his/her participation in any extra-curricular activity conducted by the Whitehall Public Schools under the following conditions:
No member of the Board Of Trustees, Whitehall Public Schools or employee thereof will, under any circumstances be held liable for accident; illness, fatality or medical bills incurred as a result of participation in the athletic program or associated trips.
As a parent or guardian, I understand that the school and the staff will do everything possible to prevent any accidents over which they have control. However, I fully understand that participation in extra-curricular activities involves inherent risks to students regardless of all feasible safety measures that may be taken by the district. In consideration of the district's agreement to allow my child to participate in this athletic program, I agree to accept responsibility for any loss, damage, or injury to my child that occurs during my child's participation in this sport or any travel related to it that is not the result of fraud, willful injury to a person or property or the willful or negligent violation of a law by a trustee, employee or agent of the Whitehall School District.
In the event it becomes necessary, I give my permission for the district staff in charge to obtain emergency care for my child. Neither he/she nor the school district assumes financial liability for expenses incurred because of an accident, illness and/or unforeseen circumstances.

Parent/Legal Guardian Signature*

Signature Required

Confirmation Email

Confirmation Email *

Email Required