St. Bernard School Athletic Association

2011-12  Permission to Participate in Athletics

Physician’s Release

(Student’s name)____________________________________ has been examined by me, and I hereby certify that he/she may participate in competitive sports programs at St. Bernard School.

Signature of Physician: ________________________________________ Date: ___________________

Office/Address: ________________________________________________Phone: _________________

Physician’s signature must be dated AFTER May 31, 2011; form will remain effective for the entire school year if submitted for a fall sport; OR for a period of not more than 12 months from the date of the physician’s signature.

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 Parent’s Release

In consideration of my child, ____________________________________ (student’s name) being allowed to participate in competitive sports programs, I/we do hereby release and forever discharge St. Bernard Catholic Grade School, of the City of Pittsburgh, PA, and/or the St. Bernard School Athletic Association, or their successors, from any and all actions or suits in law or equity, which I/we may hereafter have, by reason of injuries sustained by my child during participation in sports programs or in transit to/from participation in sports programs.

Further, I/we do hereby agree that in case of injury to my child, I/we will apply any applicable health insurance toward the payment of expenses incurred, and will look to the Diocese only for payment of any possible balance remaining after said application of all available health insurance policies. 

Signature of Parent/Guardian: ________________________________________ Date: _____________

Signature of Parent/Guardian: ________________________________________ Date: _____________

My child is covered under a current health insurance program:       YES          NO

Primary Health Insurance: _____________________ Policy #: _______________  ID #: _______________

Subscriber: ____________________________________  Relationship to child: _____________________

Employer: _____________________________________  Employer’s Phone: _______________________

Employer’s Address: ____________________________________________________________________

Other Health Insurance: ______________________ Policy #: ________________ ID #: _______________

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Date Rec’d:________________________ Approved:_________________________________________________________ Principal