WEBSTER TRANSITIONAL SCHOOL
ATHLETIC REGISTRATION FORM
Athlete _______________________________ Grade ________ Sport ____________________
We have received a copy of the extra-curricular code, printed annually in the Webster Transitional School
Student/Parent Handbook. We agree to abide by the code and acknowledge the failure to abide by the code
can result in loss or limitation of the privileges of participation in Webster extra-curricular activities. Refer to
pages 37 and 38 of the 2012-2013 Handbook.
I hereby give my permission for my son/daughter to participate in the above-referenced sport at Webster
Transitional School. I agree to be financially responsible for the safe return of any equipment/supplies issued
to him/her. I further grant permission to school personnel to provide immediate emergency care or secure
ambulance service in the case of illness or injury that may occur during participation. I realize that there is a
risk of being injured that is inherent in all activities. I realize the risk of injury may be severe.
RELEASE, WAIVER, AND INDEMNIFICATION OF LIABILITY:
The undersigned Party and Parent/Guardian (if applicable) agree to release, defend, indemnify, and hold
harmless the Cedarburg School District (“District”) and its Board, its officers, employees, agents, servants,
representatives, contractors or subcontractors, from any and all liabilities, claims, demands, actions, damages,
loss, expenses, and judgments, including costs and attorneys’ fees, whether sounding in tort, contract,
administrative law, or otherwise, and related in any way to the above travel, including but not limited to any
personal injury to any participant of any kind.
SIGNATURES: ________________________ __________________________ ____________
(Athlete) (Parent/Guardian) (Date)
PARENT/GUARDIAN INSURANCE: (Please check one)
____ We have adequate insurance coverage. ____ We will contact the school about purchasing insurance.
ATHLETIC EMERGENCY TREATMENT AND PARTICIPATION CLEARANCE
Athlete Name _________________________________________ Grade _______________
Address ______________________________________________ Home Phone ___________________
In Case of Emergency, Call: DR. _________________________________ Phone ________________
1. (Parent/Guardian) ____________________________________________ Phone ________________
2. (Relative/Neighbor)____________________________________________ Phone ________________
I grant permission to school personnel to provide emergency care or secure ambulance service in the case of
illness or injury that may occur during participation.
PARENT/GUARDIAN SIGNATURE ___________________________________ Date ________________
STUDENT’S HEALTH INFORMATION
For the safety of your son or daughter, please indicate any health conditions, restrictions, or special
precautions that should be taken _____________________________________________________________
Is it necessary for your child to take medication (prescribed or over-the-counter) while on the field trip?
______ Yes ______ No
Name of Medication _______________________________ Dosage _______________ Time ____________
If it is necessary for your child to take medication, please send the medicine in the original container, clearly
labeled with your child’s name. If school staff will need to assist with medication administration, all medicine
must be accompanied with written directions and consent from the parent/guardian, and if prescription
medication is involved, a written statement from the child’s physician. (This is a state law.) The required
medication forms can be obtained from the school office.
If I am unable to be contacted in the event of a medical emergency, I hereby authorize the treatment,
administration of anesthesia and/or surgical treatment(s).
Parent/Guardian Signature _____________________________________ Date _______________________