VRSM Student Participation Waiver -2024

Your name *

Email address *

Participant Information

Participant's First Name *

Participant's Last Name *

Phone number *

Participant's Gender *

Participant's Current Grade *

Participants Shirt Size *

Emergency Contact Name *

Emergency Contact Phone Number *

Relationship to Participant *

Parent/Guardian Information

Parent/Guardian First and Last Name *

Phone number *

Relationship to Participant *

Family Physician's Phone Number *

List below (or write "none") any allergies, medical, physical or mental conditions. Please be complete, even if you do not currently consider any such condition significant. *

Should the participant require medical attention at any time, list any special instructions (or write "none") which the participant might require such as being allergic to penicillin, having a rare blood type, etc. Again, please be complete,. *

Do you have any regular medications you will need to take? If yes, please list Medications & Schedule *

Declined Over the Counter Meds (Please select all that apply) *

The following over-the-counter medications may be administered by an adult sponsor in accordance with standard label directions. Please select any medications you request NOT be administered to your student.

No Restrictions on OTC Medications

Tylenol

Ibuprofen

Antihistamine

Decongestant

Cough Medicine

Current Immunization (give date, or write "none" or "current")

Is Parent/Guardian (person filling this out) authorized to approve medical treatment? *

YES

Is Participant covered by personal/family medical insurance? *

YES

Insurance Company Name

Signature

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

I understand *

I understand

Participant Signature *

Parent/Guardian Signature *

Participant Information

Emergency Contact

Parent/Guardian Information

Medical Information

Current Immunization (give date, or write "none" or "current")

Medical Insurance

Signature