Jefferson Academy
Athletic Medical Release Form

Athletic Insurance Waiver

NOTE: I fully understand that the Jefferson County Schools do not provide any accident or health insurance coverage for my son/daughter while participating in interscholastic athletics. I fully understand that it is my responsibility to provide insurance coverage for my son/daughter.

DATE:   SIGNED    
      PARENT ATHLETE

Statement by Physician for Athletic Participation

I hereby certify that I have examined ____________________________ and that the student was found physically fit to engage in baseball, basketball, cross-country, football, golf, gymnastics, lacrosse, soccer, softball, swimming, tennis, track, volleyball, wrestling, soccer, other. (Please cross out any sport in which the student should not participate).

DATE:   SIGNED:  
(Valid 365 days unless rescinded)   Physician, Physicians Asst. or Nurse Practitioner

Summary Information for Physician

Rule 1, Section 9, Page 32
No pupil shall represent his/her school in inter-school athletics until there is a statement signed by his parents of legal guardian and a practicing physician certifying that he/she has passed an adequate physical examination within the past year: that in the opinion of the examining physician he/she is physically fit to participate in athletics; and that he/she has the consent of his/her parents or legal guardian to participate on file with the superintendent or principal.

NOTE: It is strongly recommended by the Colorado Department of Health that individuals participating in athletic events have current tetanus boosters. Tetanus boosters are recommended every ten years throughout life. Boosters are recommended at the time of major injury if more than five years have elapsed since the last booster.

If significant intervening illnesses and/or injuries have occurred, a more complete physical examination should be conducted. A practicing physician must sign the physical examination form. If a student athlete has been injured in practice and/or competition, the nature of which required medical attention, the student athlete should not be permitted to return to practice and/or competition until he/she has received a release from a practicing physician.


Jefferson County Public Schools
Parent Permission for Athletic Participation

  1. Before an athlete is permitted to participate in the Jefferson County athletic program this permission form must be signed for each sport and on file with the school.
  2. The School District is relieved of any or all liability for accidents or injuries connected in any way with the competitive athletic program.
  3. It is the responsibility of the parent or guardian to provide insurance protection for the athlete while participation in competitive athletics.
  4. The School District makes available student insurance plans which offers coverage for any accident or injury resulting from participation in competitive athletics. This plan is available each fall at your local school. (Check with your school athletic director).
  5. Occasionally your son/daughter may travel to practice or a scheduled athletic event in student driven cars if bus transportation cannot be scheduled. If you object to this procedure, please notify your high school Athletic Director in writing.

NOTE: Although participation in supervised school athletic and activities programs are among the least hazardous events in which any student will engage either in or out of school, the very nature of these school athletic and activities programs does create potential for injury. Parents should be aware that the chance of injury is present while students are participating in school activities and athletics and should understand this includes a risk of injury which may range in severity from minor to long term catastrophic up to and including death. Those parents who do not wish to expose their students to this possibility should not sign this permission form.

I hereby give my consent for __________________________________ (name of athlete) to compete in athletics for ______________________________________ (school) in Colorado High School Activities Association Approved Sports except those crossed out below: baseball, basketball, cross-country, football, golf, gymnastics, lacrosse, soccer, softball, swimming, tennis, track, volleyball, wrestling, other.

DATE:________________ SIGNED:____________________________________


Authorization and Consent to Treat a Minor

Pursuant to Colorado Civil Code:

The undersigned do hereby authorize Jefferson Academy Personnel or such substitutes as he/she may designate as agent for the undersigned to consent to x-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment and hospital care for _______________________________ (name of minor) which is deemed advisable by and to be rendered under general or special supervision of any physician and surgeon, licensed under the Provision of Medicine Practice Act or any dentist licensed under the Dental Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, or elsewhere.

The authorization will remain effective while the above minor is en route to or from or involved or participating in Jefferson Academy Athletics, unless revoked in writing by the undersigned and delivered to the aforementioned agent.


SIGNATURE OF PARENT OR GUARDIAN             DATE


Staff / Parent Student Driver Authorization

This authorization is for driving student participants to practices or scheduled athletic events or activities by private vehicle. (The district does not insure privately owned vehicles.)

Any licensed driver 17 years or older may be authorized to drive participating students to scheduled school activities provided the vehicle meets the conditions outlined below:

  1. The vehicle to be driven will be in good working condition.
  2. The vehicle has liability insurance coverage which meets the minimum standards of the Colorado Financial Responsibility Law.
  3. The number of passengers carried shall not exceed the capacity of the vehicle.

The insurance company providing coverage for my vehicle is:


COMPANY NAME                                                                           POLICY #

I verify that the vehicle used on this student travel experience will meet the conditions outlined above.

   
DRIVER'S SIGNATURE DRIVER'S LICENSE NUMBER
   
SIGNATURE OF DRIVER'S PARENT DATE

Student Passenger of Private Vehicle Transportation

I am aware that my student may be riding to practice and/or scheduled athletic/activities with an authorized 17 year or older driver who has a valid driver’s license and is operating an auto which is insured and in good working condition.

____ My student has permission to ride with an authorized driver.

____ My student does not have permission to ride with an authorized driver.


PARENT / GUARDIAN SIGNATURE                                                  DATE

I have authorized the designated driver indicated above to transport student participants to practice and/or scheduled athletic activities.


ADMINISTRATOR'S SIGNATURE                                                         DATE

Print this form     Close window