VIRGINIA BEACH CITY PUBLIC SCHOOLS
LANDSTOWN MIDDLE SCHOOL
Intramural Activities Consent AND Emergency Form
|STUDENT NAME | |GRADE | |AGE | |
|Please list any significant health problems that might be significant to a physician evaluating your child in case of an emergency: |
| |
| |
| |
|Please list allergies including allergies to medications: | |
| |
|Has student been prescribed an inhaler or epipen? | |
|Does the student wear contact lens? | | | |
|EMERGENCY AUTHORIZATION: In the event I cannot be reached in an emergency, I hereby give permission for Landstown Middle School to secure necessary aid and |
|transportation for the preservation for the person named above. |
|Daytime phone number (where to reach you in emergency) | |
|Evening time phone number (where to reach you in emergency) | |
|I certify that all of the above information is correct and give my consent and approval for the above named student to participate in the Landstown Middle Intramural|
|Program. |
|Signature of parent or guardian | |Date | |
|Relationship to student | |
| |
| |
In order to participate in the Landstown Middle after-school intramural program, students are expected to adhere to the following guidelines:
❑ Follow all school rules as stated in the student planner/handbook.
❑ Be on time and dress appropriately for the activity.
❑ Remain in the areas set aside for the program.
❑ Provide the teacher with a written note from parent/guardian if the need arises to leave before the scheduled end of the program.
❑ FAILURE TO FOLLOW THE ABOVEMENTIONED GUIDELINES COULD RESULT IN THE SUSPENSION OF INTRAMURAL PRIVILEGES.
THIS FORM MUST BE RETURNED TO The INTRAMURAL SPONSOR IN ORDER TO PARTICIPATE.
Students must have a separate intramural form for each intramural in which they participate.
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