St. Theresa Parish Athletic Association

PARENTAL CONSENT & EMERGENCY AUTHORIZATION FORM

I, the parent or guardian whose signature appears below, grant permission and consent for my child to participate in the STPAA program noted below for the 2002-2003 season. I understand and have been informed that taking part in athletic competition involves the risk of injury. Injury may be minor, but there is always the risk of lifelong impairment or even death. I further understand that transportation may include private vehicles to and from practices, games, and tournaments.

I hereby grant consent for coaches, staff members and/or adult volunteers under whose auspices the program is conducted, to secure all necessary emergency medical care and/or treatment that may be necessary for my child during the entire season, including transportation, if provided by coaches, staff members, or adult volunteers. I release and hold harmless any said coach, staff member or adult volunteer from any liability, who in good faith is placed in a position requiring decisions to be made for emergency care or medical treatment of my child. In case of accident, injury, or loss, neither my family nor I will hold the parish, the STPAA, the place where the event is conducted, the group sponsoring the event, nor any person or affiliate organization associated with the event responsible or liable.

Program: Soccer Cheerleading Girls Basketball Boys Basketball Instructional Basketball Track

____________________________ _______ ______ _________________ ______________________

Name of Child Participant Age Grade Date of Birth Phone #

(Current) (02-03)

STS School ____ STS Rel. Ed ____ School _________________________

Street Address City State Zip

_________________________________ _____________________________ __________________

Name of Parent(s)/Guardian(s) E-mail Address Work Phone #

In the event of an emergency, if you are unable to reach me at the above number(s), contact:

_________________________________ _____________________ __________________________

Name of Emergency Contact Relationship to Child Phone #

_________________________________ _____________________ __________________________

Name of Family Doctor Phone # Medical Conditions

_________________________________________________________ __________________________

Allergic reactions (medications, food, insects, etc.) Medication Currently Taking

_________________________________ _____________________ __________________________

Insurance Company Policy # Group #

________________________________ _____________________ __________________________

Signature (Parent/Legal Guardian) Relationship to Child Date

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TO BE COMPLETED BY STPAA

T-shirt size Youth: S M L Registration Paid $_________

(circle one) Adult: S M L XL Fundraiser Paid $_N/A________

Total $_________

Voucher ______ Cash ______ Check #_________