INFORMATION & CONSENT FORM
To be completed by parent/guardian or 18 year old or older student-athlete; please take time to complete
the form to ensure the good health and safety of the student-athlete
Must be signed in four (4) places by parent/guardian or 18 year old or older student-athlete (Below and on page 3)
th
The exam date must be performed on or after April 15
to be valid for the following school year
Copies of the first two pages, Clearance Form and Information & Consent Form, must be kept on file with school athletic department
Student Name: ______________________________________________________________________________
Last
First
Middle Initial
Sex:______ Grade:________ Age:_______
Date of Birth:_______________
School: ___________________________________ Sport(s): _________________________________________
Student’s Address: ___________________________________________________________________________
Street
City
Zip
Father’s/Guardian Name:_______________________________________________________________________
Phone (home):________________________ (work):__________________ (cell):__________________________
Mother’s/Guardian Name:_______________________________________________________________________
Phone (home):________________________(work): ____________________(cell):_________________________
STUDENT PARTICIPATION & PARENT OR GUARDIAN OR 18 YEAR OLD CONSENT
The information submitted herein is truthful to the best of my knowledge. By my/my child’s signature below, I/we
acknowledge that I/we have received concussion educational information that meets Michigan Department of Health and
Human Services and MHSAA requirements. Further, in consideration of my/my child’s participation in MHSAA-sponsored
athletics, I/we do hereby agree, understand, appreciate, and acknowledge: that participation in such athletics is purely
voluntary; that such activities involve physical exertion and contact and that there is inherent risk of personal injury
associated with participation in such activities, which risk I/we assume; and that I/we agree to, and hereby, waive any and
all claims, suits, losses, actions, or causes of action against the MHSAA, its members, officers, representatives,
committee-members, employees, agents, attorneys, insurers, volunteers, and affiliates based on any injury to me, my child,
or any person, whether because of inherent risk, accident, negligence, or otherwise, during or arising in any way from
my/my child’s participation in an MHSAA-sponsored sport.
I/we understand that I am/we are expected to adhere firmly to all established athletic policies of my school district and the
MHSAA
I/we hereby give my consent for the above student to engage in interscholastic athletics and for the disclosure to the
MHSAA of information otherwise protected by FERPA and HIPAA for the purpose of determining eligibility for
interscholastic athletics. My child has my permission to accompany the team as a member on its out-of-town trips.
Signature of STUDENT: ___________________________________________ Date: __________
____________________________________________________________________
________________
Signature of PARENT OR GUARDIAN OR 18 YEAR-OLD
Date
INSURANCE STATEMENT:
Our son/daughter will comply with the specific insurance regulations of the school district.
The student-athlete has health insurance: Yes
No
If yes, Family Insurance Co: _____________________________ Insurance ID # __________________________
MEDICAL TREATMENT CONSENT:
I, _______________________________________, an 18 year-old, or the
parent or guardian of _________________________________, recognize that as a result of athletic participation, medical
treatment on an emergency basis may be necessary, and further recognize that school personnel may be unable to contact
me for my consent for emergency medical care. I do hereby consent in advance to such emergency care, including
hospital care, as may be deemed necessary under the then-existing circumstances and to assume the expenses of such
care.
____________________________________________________________________
________________
Signature of PARENT OR GUARDIAN OR 18 YEAR-OLD
Date