Student Name __________________________________ Birthday ________ Telephone _____________ Sex _____ Grade _____

Janesville Edison Middle School Interscholastic/Intramural Sports Card

Part A. Parent Permission Section
I hereby give my permission for the above named student to practice, compete, and represent Edison in approved after school sports. As parent (or legal guardian) of the above named student, I agree to be financially responsible for the safe and prompt return of all athletic equipment issued to (him or her). I realize that failure to do so may result in financial or legal consequences.

Part B.

Athletic Code

We, the undersigned, have read and understand the Athletic Code of the School District of Janesville currently in effect and agree to abide by all of its provisions. This agreement is binding through the student's current middle school year and is to be renewed every year.

Part C.

Parent Signature

By signing this section I am affirming that I have read and am in agreement with the above information as it is stated in the sections labeled Parts A, B, & C. Parent Signature _____________________________________________ Date __________________________________ Student Signature _____________________________________________ Date __________________________________ (Return entire card to the school office or coach)

Student Name __________________________________Birthday _________ Telephone _____________ Sex _____ Grade _____

Part D.

Insurance Certification

This is to certify that the above named student is currently enrolled at Edison Middle School and has current accident insurance in the following company comparable to the School District of Janesville's Accident Benefit Plan offered. Name of Insurance Company _________________________________ It is understood that no claims for an injury as a result of Interscholastic Athletics will be made against the school or the WIAA. (A reminder: If your employment status changes, the possibility does exist that your child would not be covered).

Part E.

Permission for Medical Treatment

In the event of an emergency requiring medical attention, I hereby grant permission for a physician or other hospital personnel designated by the Janesville Public Schools to treat my son/daughter. I further grant permission for my son or daughter named above to be given immediate emergency care in case of injury as the result of athletic competition by a physician or hospital personnel. Every effort will be made to contact the parent or guardian first in order to receive my specific authorization before any treatment or hospitalization is undertaken. Parent Signature _____________________________________________ Date __________________________________ Home Phone ____________________ Work Phone _____________________ Cellular Phone ____________________ Doctor Name _________________________________ Dentist Name _________________________________________ Name of Insurance Company____________________________________________________________________________ Health History Kidney Injuries: Yes No Heart Condition: Yes No Diabetes: Yes No Asthma: Yes No Glasses/Contacts: Yes No Bee Sting Allergy: Yes No Medication Allergies? Please state: ____________________________________________________________________________ Other comments: ___________________________________________________________________________________________

Note: Although a dental/physical examination is not required as a prerequisite to athletic participation, it is recommended that your son or daughter visit a dentist or doctor regularly and that a good health program be maintained. We also request that you inform us of any medical situation, which could create any problem for your son/daughter.