Hixson Middle School Track Program
Informed Consent Form
I hereby give permission for __________________________ to participate on the
Track Team at Hixson Middle School for the 2013-2014 school year.
A fee of $25.00 is expected for this sport.
Student’s Full Name _____________________________________________________
Parent or Guardian _____________________________________________________
Address _______________________________ DOB __________________
Phone No. ___________________________________________________
Cell No. ___________________________________________________
Alternative Number _____________________________________________
Other person to contact in case of an emergency
Name _____________________________________________ Relation __________
Family Physician ______________________________________ Phone ____________
Medical conditions (e.g., allergies, chronic illness) ______________________________
We understand that each athlete must be a positive representative of Hixson Middle School. He/she must uphold our school’s reputation, exhibiting strong spirit and good sportsmanship at all games. Members not adhering to the above conditions will be removed from the team.
We understand this informed consent form and agree to its conditions.
Child’s Signature ______________________________ Date ___________
Parent’s/ Guardian’s _______________________________ Date ___________ Signature