Saint Rose High School

Saint Rose High School Athletic Department 607 7th Avenue Belmar, New Jersey 07719 Phone: 732-681-1021 Fax:732-681-0157

Agreement to participate in a Spring Interscholastic Sport

Name: ______Grade: _____ Homeroom ______Transfer Student: _____ Yes _____ No Office Use: Date of Physical: ______Date Cleared:______

BASEBALL – GOLF – LACROSSE – SOFTBALL – TENNIS - TRACK

I realize that the above sports are vigorous physical activities which sometimes involve: - Violent body contact, strenuous exertion, rapid directional changes, inadvertent physical contact I understand that participation in the above sports involves certain inherent risks and that regardless of the precautions taken by ST. ROSE HIGH SCHOOL or the participants, some injuries may occur. These injuries might include, but are not limited to: -Knee injuries, broken bones, sprained ankles, concussion, back injuries, quadriplegia, death These injuries may result from hazards such as: -Heading the ball, uneven playing surfaces, contacting goal posts or other solid objects, being struck by golf/tennis balls, violent bodily contact, strain or exertion The likelihood of such injuries may be lessened by adhering to the following safety rules: -Being in good physical condition, obeying and paying strict attention to the training rules, reporting any physical hazards to the coach In order to properly protect my own safety and that of my fellow participants, I agree to follow these rules as well as any others that may be given by my coaches. Further, in recognition of the importance of shared responsibility for safety, I agree to report any noted deviations from the safety rules as well as any observed hazardous conditions or equipment to my coaches. I further certify that my present level of physical condition is consistent with the demands of active participation in any of the above sports. PARENTS PERMISSION

NAME ______Grade ______

Requests enrollment on the ______team. I have complied with all eligibility requirements and have obtained the necessary insurance. I understand that I am responsible for all items of equipment issued to me and that I will pay for all items lost, stolen or misplaced.

Date ______Parent Signature______

I have read and understand the information on Sudden Cardiac Death , Concussion and Consent to Steroid Testing that is posted on the SRHS Athletic Website Forms Page.

Date______Student Signature______

Date______Parent Signature______The following is a list of all my known health conditions which might affect my ability to participate: ______

I have carefully read the foregoing document. I have had the opportunity to ask questions and have them answered. I am confident that I fully know, understand and appreciate the risks involved in active participation in ______and I am voluntarily requesting

permission to participate.

Student Signature: ______Date:______

Parent Signature: ______Date:______

Grade: ______Homeroom: ______

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Please complete the following information for our records:

Last Name: ______First Name: ______

Address: ______Town: ______Zip______

Email Address: ______

Public School District: ______

Phone: ______Sex: M or F (circle one)

Date of Birth: ______Age: ______

Father's Name:______Phone: ______

Mother's Name: ______Phone: ______

City and State where you were born: ______

Date you entered St. Rose High School: ______

Did you transfer from another high school to St. Rose HS?______

If so, which high school? ______

Important Notice: If you have transferred from another high school in the past year, you are required to file a transfer waiver form with the NJSIAA. You may NOT compete in a game or scrimmage until these forms have been processed. Pick up these forms at the Athletic Director’s office as soon as possible.