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Athletic Participation Application and Consent

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Participation Application and Consent

  • Family PhysicianPhysician's AddressPhysician's Phone 
  • PARENTAL PERMISSION, ACKNOWLEDGMENT AND RELEASE

    1.  PARENT/LEGAL CUSTODIAN/LEGAL GUARDIAN VERIFICATION. The undersigned parent/legal custodian/legal guardian or person enrolling student pursuant to an Affidavit of Hardship hereby certifies that he/she is the biological parent, legal custodian or legal guardian of Student or person enrolling Student pursuant to an Affidavit of Hardship and that, immediately upon request by Catawba County Board of Education or its employees [herein "CCBOE"], he/she shall provide any and all documentation requested by CCBOE to verify his/her relationship to Student. The undersigned further acknowledge and agree that in the event sufficient and satisfactory documentation is not provided to CCBOE, Student may be removed or excluded from participation in interscholastic athletic events, practices and play. 

    2.  PROGRAM COMPLIANCE. The undersigned hereby certify that the information contained in this application and completed North Carolina High School Athletic Association Sport Pre-participation Examination Form is true and correct. The undersigned further agrees to immediately notify the Principal of Student’s school in the event of either of the following: a) there is a change in Student's medical condition; the Student begins taking any medications; and c) any change in the Student’s residence or domicile. The undersigned further agree that they have reviewed, understand and agree to abide by all of the rules and regulations governing Student's participation in interscholastic athletic events and competitions, including but not limited to, codes of conduct, policies and eligibility rules and regulations governing athletics as set forth by state and federal law, Catawba County Board of Education, North Carolina State Board of Education and the Athletic Association to which Student's school is a member. The undersigned acknowledges that in the event any information contained in this document or the North Carolina High School Athletic Association Sport Pre-participation Examination Form is determined to be false, Student shall become immediately ineligible to participate in any interscholastic athletic events for a minimum of 365 days. 

  • Hold the CTRL button to select muliple sports

  • 4.  EXPENSES. The undersigned hereby acknowledge that Student's participation in interscholastic athletic events, practice and play may involve costs and expenses which are the Student's responsibility. The undersigned further agrees to pay and assume full responsibility for the payment of these costs and expenses.

    5.  INSURANCE. The undersigned acknowledge and agree that students who participate in interscholastic athletic events shall, at all times during which Student is participating in the same, maintain and have in effect medical, health or accident insurance overage. The undersigned parent/legal custodian/legal guardian hereby acknowledges and certifies that Student is and will, during the entire period of Student's participation in interscholastic athletic events, be enrolled in and covered under the medical, health or accident insurance plan identified herein. At all times during Student’s enrollment and participation in interscholastic athletic events, the undersigned shall immediately notify the Principal of Student's school of any change in the foregoing medical, health or accident insurance coverage.

    6.  TRANSPORTATION. The undersigned acknowledge and agree that while enrolled in and participating in interscholastic athletic events, practices and competitions, the undersigned shall be responsible for transportation of Student to and from the practices, events and competitions. The undersigned parent/legal custodian/legal guardian hereby grant unrestricted permission for Student to travel to interscholastic athletic events, practices and competitions and all other activities related to Student’s participation in interscholastic athletics. In the event transportation to and from practices, events, and competitions is provided by the school, the undersigned consents to Student being transported by the school.

    7. IMAGE RELEASE. The undersigned assign, transfer and grant to CCBOE and its agents, employees, successors, assigns and those by whom it is commissioned, the absolute, unrestricted and unlimited license, right, permission, and consent to make photographic, video and audio recordings of student’s image, likeness and voice and to use, disseminate, copyright, print, reproduce and publish for any and all trade, commercial or other advertising or public purposes, and in any all advertising, publicity, display, publication or media, for such purposes as CCBOE deems appropriate, student’s name, signature, likeness, portraits, pictures, photographic prints, videos, audio tapes, tracks or text or other representations of student or in which student may appear or any reproductions or sketches thereof or parts thereof, with such additions, deletions, alterations or changes therein as CCBOE may make, either separately or together with student’s name, or a fictitious name or the name of another person, with or without, any statements or testimonials made or authorized by the undersigned which CCBOE may, in its discretion, prepare for use in connection therewith. The undersigned have not limited or restricted the use of Student’s name or photograph to any entity or person.

    8.  CONSENT FOR RELEASE OF RECORDS AND INFORMATION Pursuant to 20 U.S.C §1232g; 34 CFR Part 99 (FERPA). The undersigned hereby acknowledge and agree that the educational records and other records or information relating to Student, including personally identifiable information from Student’s records, may be protected pursuant to the Family Education Rights and Privacy Act (20 U.S.C. §1232g and 34 CFR Part99) and, therefore, may not be released by any school officials of CCBOE without the written consent and permission of the Student and Parent/Legal Custodian/Legal Guardian. CCBOE and its employees and officials are hereby authorized to the release, disclose and share the following records and information relating to Student with and to College or University Athletic Recruiters, Scouts or Coaches for the purpose of enhancing the possibility of scholarship assistance for further education of said student and encouraging, supporting and fostering said student's career in college and professional sports: Physical and athletic abilities and limitations, academic ability, academic progress and standing, official grades and academic scores, potential athletic ability, leadership ability, attitude, past behavior, behavioral characteristics, medical condition, medical history, medical records and information and identification of said student's participation in sporting events. CCBOE and its employees and officials are hereby authorized to the release, disclose and share the following records and information relating to Student with and to Members of the Media, including but not limited to, Newspaper and Television Reporters for the purpose of providing information, tracking information and clarification of activities and the condition of Student to interscholastic sports fans who support, encourage and follow interscholastic athletics: Medical condition, status, treatment and progress of injuries which may affect the performance of Student in interscholastic athletic events, training, practice and competition and the identification of said Student's participation in interscholastic athletic events. The undersigned hereby acknowledge that each has the right to 1) refuse to sign this Consent, 2) revoke this Consent, in writing, by sending written notification to CCBOE, and 3) inspect and copy the personally identifiable information and records to be disclosed. By their signatures affixed below, Student and Legal Custodian/Legal Guardian hereby consent to the release, disclosure and sharing of information and records relating to Student as set forth herein.

    9.  RELEASE OF LIABILITY: The undersigned hereby give consent and permission for Student to practice and play in interscholastic athletic events for Catawba County Board of Education. The undersigned further agree that it is necessary for Student to undergo a medical examination to determine whether he or she is medically qualified or not medically qualified to participate in the above-named interscholastic sports. The undersigned further agree that Student's participation in interscholastic athletic events subjects Student to the possibility of physical illness or injury (including minimal, serious, catastrophic and/or death) and that the undersigned are assuming the risk of such illness or injury by Student's participation in interscholastic athletics practice, play and competitions. The undersigned hereby grant permission for Student to receive treatment from medical providers which is deemed necessary for a condition, illness or injury arising during practice or play of the interscholastic athletics, including, but not limited to, medical or surgical treatment recommended by a medical doctor. For good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the undersigned does hereby, for their heirs, executors, administrators, successors and assigns, release, acquit, and forever discharge Catawba County Board of Education, and its agents, employees, servants, successors, attorneys and all other persons, corporations, firms, associations, or partnerships claiming by, through, or under it, of and from any and all claims, claims for negligence, actions, causes of action, demands, rights, damages, costs, losses of service, expenses, and compensation whatsoever which the undersigned now has or which may hereafter accrue with respect to Student's participation in interscholastic athletics, events, practice, play and competitions, including transportation to and from such activity, and further including any and all known and unknown, foreseen and unforeseen, damage and the consequences thereof resulting or to result, or arising out of or through, any and all actual, alleged, or implied rights, claims, actions, or causes of action which the undersigned may have or which may hereafter accrue against Catawba County Board of Education. The undersigned further declare and represent that no promise, inducement, or agreement not herein expressed has been made to the undersigned.

  • (All participants in interscholastic athletics must be enrolled in an accident insurance policy through Student's school or must have independent medical insurance coverage.)

    If yes, please send a copy of insurance card to the Athletic Directors office. 

    If yes, please send a copy of insurance card to the Athletic Directors office. 

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