Student Name  ___________________Date _____________ Grade Level  __6    7     8_(circle one)_

Winston Salem/ Forsyth County

Meadowlark Middle School

Intramural / Parent Permission Form

The written permission of a student's parent/guardian is required for participation in intramurals, after school activities, and athletic team tryouts.  In addition, the school system requires that the parents assume financial responsibility for all medical and hospital bills incurred as a result of an accidental injury their child sustains while involved in the program.  Intramurals and athletics do involve some risk of physical injury to the child.  Parents should be aware of these risks before granting a child permission to participate. 

I, _______________________( Parent/Guardian Name ), grant my child permission to participate in intramurals and athletic tryouts at Meadowlark Middle School.    

I certify that my child has no known medical or physical condition that might make participation in intramurals and athletics detrimental or hazardous to his/her health with the possible exception of: (please list and describe)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

If my child suffers an accidental injury while participating in intramurals or athletics, I agree to pay all of the medical and hospital bills. 

I also grant permission for school officials to obtain necessary medical treatment for my child in an emergency when I cannot be contacted.  I understand that reasonable efforts will be made to contact me prior to treatment. 

Participants are expected to be picked up within 15 minutes of the scheduled intramural end time. If participants are picked up late consistently, they are subject to being dismissed from our intramural program.

Parent(s) Name ________________________                             _________________(Primary phone)

Address__________________________                                    ______________ (Secondary)

__________________________                                ________________ (Additional)

Emergency Contact Name_____________                              (Phone) _____________

Parent Signature___________________________ Date_____________