Click Here to Download this Form- Parent Consent Form for Sports
    City School District
                                          Rochester, New York


    Parent’s consent to Pupil Participation

    In Clubs, Games and Competitive Sports


    School: __________________________________ Date: _____________


    To the Principal:


    I ________________________ the parent/guardian of ____________________ hereby permit him/her to engage in club activities, activities, after-school games, athletics and competitive sports, as conducted by the public schools and at my risk.  If, at anytime, I deem that the continuance of this permission is inadvisable, I must notify the school principal in writing.  I have read the policy of RCSD concerning accidents printed below on this form and agree to allow my child to participate under these conditions.


    I permit him/her to receive an athletic physical offered by the RCSD as conducted by the Monroe County Health Department if my child is to participate in interscholastic athletic sports or to submit an athletic physical from the physician of my choice.


    This consent shall be valid as long as my child remains a student in RCSD or until I revoke consent in writing to the principal.




    ______________________________   __________________________

    Student Signature                                 Parent/Guardian Signature


    1.      MINOR INJURIES:  Treatment of cuts, bruises, abrasions, etc., is in general rendered by the Community Health Nurse (C.H.N.) of the Monroe County Health Department.  In the absence of the nurse, treatment is rendered by the Health or Physical Education teacher, school staff or other available person.

    2.      MAJOR INJURIES:  Send injured pupil to hospital nearest to the school by ambulance or taxi cab.  Pending its arrival, first aid is rendered by C.H.N. or other available person.


    3.      TREATMENT AT HOSPITAL: On arrival at the hospital, medical treatment is rendered by hospital staff.  Supervision of the case by RCSD ceases.

    4.      NOTIFICATION OF PARENTS:  Whenever possible, the parent is notified of an injury to a child, but necessary medical attention is not delayed on delayed on this account.

    5.      PAYMENT FOR MEDICAL SERVICES IN CASE OF INJURY: Every RCSD student is covered by a School Accident Insurance Policy issued by Blue Cross/Blue Shield, which provides minimal coverage in case of injury.  Note: In case of injury, it is the parent’s health coverage, if any, which must first be applied to cover medial costs. Only after the parent’s health insurance benefits are exhausted does the School Accident Policy applies and then only up to the policy limits.  Parents may be responsible for medical costs beyond the policy limits or which are not reimbursable under the School Accident Policy.


    This parent permission form must be signed by the parent/guardian and the student and filed with the school athletic director.  The Athletic Director then submits the student’s name to the nurse for a physical.