Activities - SIGNATURE PAGE

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SIGNATURE PAGE

**This Form must be returned to the Activities Director before the student may participate in any extra-curricular activity at Washington Middle School or Dawson County High School.

What School Does your student participate in?

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Co-op School

DCHS

WMS

Both - Possible 8th grader playing up in a sport

Click on the links below to access the Activities Handbooks:

DCHS Activities Handbook

DCHS Activities Handbook Video 26-27

Click on the links below to access the Activities Handbooks:

WMS Activities Handbook

WMS Activities Handbook Video 26-27

Student's Name

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Parent's Name

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Parent's Email

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Drug Screening Policy:

I have received and have read and understand a copy of the “Dawson County High School Extracurricular Activities Drug Testing Program” policy.

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I have received and have read and understand it

My Student (listed above) will participate in this program and in extra-curricular programs at Dawson County High School and hereby agree to be subject to its terms for the entire high school career (grade 9-12).

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I agree

I accept the method of obtaining urine and/or saliva specimens, testing, and analyses of such specimens and all other aspects of the program. I agree to cooperate in furnishing urine and/or saliva specimens that may be required from time to time.

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I accept

I further agree and consent to the disclosure of the sampling, testing and results provided for this program to school administration.

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I further agree and consent

This consent is given pursuant to all State and Federal Privacy Statutes and is a waiver of rights to nondisclosure of such test records and results only to the extent of the disclosures in the program.

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I understand and give consent

Parent/Guardian Statement:

Name of student

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I/We hav watched the GPS Activities Handbook Video

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Yes, I have watched it

I/we hereby certify and affirm that I/we are the parent(s)/legal guardian(s) of the student listed above.

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I certify and affirm

I/We understand and have read the warnings listed in the WMS or DCHS handbook for the activities in which the above student will participate or have watched the video provided by GPS.

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I/We understand and have read

I/We are cognizant of its terms and understand that all sports/activities can involve many risks of injury including, but not limited to, those risks indicated within this handbook.

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I/We are cognizant

I/We hereby assume all risks of playing or practicing to play/participate for the above named student.

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I/We hereby assume all risks

Furthermore, I/we release and waive, and agree to indemnify, hold harmless or reimburse the school district and the individual members, agents, employees and representatives thereof, as well as sport/activity supervisors and coaches, from and against any claim which the above named student, I/we, and /or other parent(s) or guardian(s), and sibling, or any other person, firm or corporation may have to claim to have known or unknown, directly or indirectly, for any losses, damages or in connection with the participation by the above named student.

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I/We release and waive, and agree to indemnify, hold harmless or reimburse

I/We understand that by signing this warning, agreement to obey instructions, and assumptions of risk, I/we are waiving all the rights that the above named student, I/we, or any other person may have to any compensation for any physical injury that may result from participation by the above named student.

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I/We Understand

I/We have read and understand the information contained in this form and will abide by the contents of this document.

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I Understand

Parent/Guardian Signature

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Student Participant Statement:

Please make sure the student reads and signs below.

I understand that Dawson County High School and Washington Middle School have both a Training Rules Policy and an Academic Eligibility Policy as outlined and discussed in the respective handbooks and provided to me in the video. Coaches and supervisors may have additional policies and guidelines of which I am expected to abide. I have read the policies and I understand my expectations as a participant.

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I Understand

I have read and understand the information contained in this form and will abide by the contents of this document.

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I Understand

Student Signature

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