Athletics Medical Release Card

Please complete the form below. Mandatory fields marked *

Student Information
Parent(s) or Legal Guardian(s) Permission/Consent

I request that the above named student be allowed to participate and engage in athletic activities as a representative of Ivy Academia Charter School, and hereby give my consent for the same. I also request that, and give my permission for, the above named student to accompany the team as a member to its non-home games. I give permission for a physician to treat my son/daughter whenever necessary until other arrangements can be made and for the coach or assistant coach to render first aid if he/she is qualified to do so. In case of injury, the Parent or Guardian will be notified, and they are to refer the student to their own physician. IN CASE OF AN EMERGENCY, the student will be taken to a facility that can treat him/her immediately, transported by a school official or by an emergency vehicle, accompanied by a school official.

Your signature in this situation is imperative and authorizes this treatment. It is also understood that as a parent/legal guardian, you accept full financial responsibility regarding medical treatment.

By typing my name below I certify that all the information on this form is accurate and complete and I consent to have the above named student participate in athletics.
  1. In case of emergency and I cannot be reached, I request and authorize Ivy Academia Charter School to contact the following persons: