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Vance Charter School Athletic Participation Form

Name:_______________________________________D.O.B.____________Grade:__________

Parents' Name:______________________________________________________________________

Address:________________________________City________________________State:______

Day/Work Phone:___________________________(Mother) Home Phone:_________________

Day/Work Phone:___________________________(Father) Home Phone:_________________

Cell Phone:___________________

In case of emergency and parents cannot be reached, please contact:

______________________________________________________________________________

Student's Physician:_____________________________________________ Phone:_________________

Student's Insurance Information: Company:__________________________________________________

Policy #: ____________________________________

As parent/guardian, I give permission for my child's participation in athletic events.

In the event of a medical emergency, I give Vance Charter School permission to authorize necessary medical care if I cannot be reached or if the situation warrants immediate action.

Parent/Guardian
Signature:__________________________________________________Date:______________