Andover/ Whitesville Interscholastic Code of Athletics Consent Form 2023-2024

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Please Fill out this form for your student(s) to participate this season

Name(s) of Student *

Insurance Coverage *

I DO carry some type of Insurance Coverage

I DO NOT carry some type of Insurance Coverage

Required

Permission for Emergency Medical Treatment: Every effort will be made to contact the parent/guardian in order to receive authorization before any treatment or hospitalization is undertaken. I Hereby grant permission for a physician or hospital personnel designated by the Andover Central School District or Whitesville Central School District designee to attend to my son/daughter. *

I grant permission

I do not grant permission

Required

Please enter contact information below (home/cell phone numbers). Please Include an emergency contact as well.

Student Signature: By Signing below, I acknowledge that:

1. I Have read the Code of Athletics between Andover and Whitesville Central Schools

2. Have read and have access to the NYSED Memo on the Dominic Murray Sudden Cardiac Arrest Prevention Act

Parent/Guardian Acknowledgements:

By Signing below, I acknowledge that:

1. I Have given the above student permission to participate in athletics during the fall sports season

2. I Have read the Code of Athletics between Andover and Whitesville Central Schools

3. I Have read and have access to the NYSED Memo on the Dominic Murray Sudden Cardiac Arrest Prevention Act

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