Madison County Elementary School

173 Wood Street

Gurley, AL 35748

Athletic Permission for Participation and Transportation Waiver

School year _________

I, __________________do hereby give my permission for __________________

(Parent or Guardian) (Student)

to participate in the athletic program at Madison County Elementary /Middle School.

I fully understand that the Madison County Board of Education requires a physical

examination of students who participate in any sport. I fully understand that neither

Madison County Elementary/Middle School nor the Madison County School System

furnishes an accident and/or disability insurance policy for its athletes. I fully understand

that I will be responsible for any medical, doctor, hospital, or related expenses

should _________________ be injured while participating as a team member

(Student)

in athletics at Madison County Elementary/Middle School, and I hereby release the

Madison County School System and all its employees from liability whatsoever and

waive any claims for compensation in case of injury to ___________________ . (Student)

Further, I certify that I have adequate insurance protection in force for _______________

(Student)

in case any injury should occur while engaged in athletics at Madison County

Elementary/Middle School.

Name of Insurance:____________________________________Policy # __________

______________________________ __________ ______________________________ __________

(Parent/Guardian’s Signature) (Date) (Principal’s Signature) (Date)

______________________________ __________ ______________________________ __________

(Student’s Signature) (Date) (Coach’s Signature) (Date)

I also hereby give permission for ____________________ to be transported to and

(Student’s Name)

from the athletic events.

_____________________________

(Parent/Guardian’s Signature)