Student First Name

Student Last Name

Date of Birth (YYYY/MM/DD)

Street Address:

Town/City:

Postal Code:

Parent/Guardian Name:

Phone #1:

Phone #2:

Person to Notify if Parent/Guardian is Not Available:

Phone #1:

Phone #2:

Student's Family Physician:

Phone #:

Check any of the following Medical Conditions if they apply:

Diabetes

Bronchitis

Heart Disease

Seizures

Contacts

High Blood Pressure

Asthma

Eye Glasses

Other

If you selected Other, please provide details.

Does your student have any allergies? (If yes, please list)

Is your student taking any medications? (If yes, please list)

Is your student allergic to any medications? (If yes, please list)

Other pertinent information concerning the student's medical history? (Attach additional information if necessary)

I give permission for my child to participate in extra-curricular athletics under NLSchools. I request that in my absence the above named be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and medical staff, duly licensed as Doctors of Medicine or Doctors of Dentistry, or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and X-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment.

Medical Declaration: To the best of my knowledge, the above named student has no problems which would prevent or limit his/her participation in any strenuous activity.

Parent/Guardian Signature:

NOTE:

- If a medical situation changes, it is the parent/guardian's responsibility to notify the school;

- In a situation where the parent/guardian cannot sign the medical declaration, the student must have a medical examination and subsequent instruction from the examining doctor detailing the degree of participation allowed.