Individual Medical Waiver/Student Information Form

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Individual Medical Waiver/Student Information Form
ANNUAL WMMHS DODGEBALL TOURNAMENT WAIVER
I give my child/ward ________________________________ permission to participate in the
(PRINT Student Name)
Mendham High School’s Annual Dodgeball Tournament on June 9th, 2015.
I understand the activity will be supervised and the school DOES NOT INSURE participants
with accident insurance and that students participate at their OWN RISK. It is understood that
this program is a physical activity and various injuries may occur. I also understand it is my
responsibility to make sure the registrant is physically capable of participating in this program
and a medical physical by a doctor is recommended.
I understand that my child must complete the registration form on the back of this waiver and
that all information submitted is, to the best of my knowledge, true and correct. Any intentional
falsifying of information will result in automatic expulsion of my child/ward from the program
and possible persecution. I agree to abide by rules, regulations, and policies as set forth. I also
understand that myself and my child must sign the school’s code of conduct in order to
participate in this event.
I agree to pick up my child or arrange for someone to pick up my child at the conclusion of the
last game of the night.
Parent/Guardian Signature: ______________________________________________________
Parent/Guardian Printed Name: ___________________________________________________
Please complete the registration form on the back and the school Code of Conduct, regardless of
if you have already signed it for another club, activity or sport.
ANNUAL WMMHS DODGEBALL TOURNAMENT
PLAYER REGISTRATION INFORMATION
Last Name:_________________________________________________
First Name:_________________________________________________
Current Grade:______________________________________________
Student Email:______________________________________________
Age:_____________
Date of Birth:________________________
Home Phone:______________________________________________
Emergency Phone:__________________________________________
Parent/Guardian Name:____________________________________________________
Medical Needs/Problems:_____________________________________
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