Skip to main content
logo
English
Spanish

Activities - STUDENT PARTICIPATION INFORMATION FORM

Activities - STUDENT PARTICIPATION INFORMATION FORM
filter submissions by this form
draft saved: 1 second ago
Complete Later
Send yourself a link to edit your response from another device.
Email
Got it!

Your submission has been received.

STUDENT PARTICIPATION INFORMATION FORM

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

Student Name (First and Last)
required
Student Birthdate
required
Student Year In School
required
No results found
12th
11th
10th
9th
8th
7th
6th
5th
4th
3rd
2nd
1st
Kinder
Parent/Guardian Name
required
Parent's Email
required
Home Phone Number
Work Phone Number
Cell Phone Number
required
Address
required

Please put whole address (Number and Street, City, State, and Zip)

EMERGENCY MEDICAL INFORMATION:

If emergency service involving medical action or treatment is required and the parent(s) or guardian(s) cannot be contacted, I/we hereby consent for the student named above to be given emergency medical care by the doctor or hospital selected by the school.

Family Physician
required
Physician Phone Number
required
Please list any medications, allergies, medical problems, and/or medical concerns of which the coach/advisor should be aware:
required
Emergency Contact
required
Emergency Contact Phone Number
required

INSURANCE:

Dawson County High School/Washington Middle School and the Glendive Unified Public School District does not carry a medical insurance policy which covers participants in athletics/activities. (Please mark below that you understand.)

Company of Family Medical Insurance
required
I/We understand that my son/daughter is covered by our family medical insurance with the listed company above.
required
I understand
I/We understand that my son/daughter is not covered by a medical policy provided by Dawson County High School/Washington Middle School (circle one) and the Glendive Unified Public School District and I/we are responsible for the payment of medical bills incurred as a result of or in relation to participation in athletics/activities at Dawson County High School.
required
I understand

ACTIVITY PERMISSION:

(PARENT INITIAL THE APPLICABLE ACTIVITIES)

Activity Permission (Please check all the applicable activities)
required
Band/Choir
Cross-Country
Golf
Volleyball
Field Trips
Flag Football
Basketball
Forensics
Tennis
Wrestling
Cheer/Dance
Football
Track
Softball

EQUIPMENT RESPONSIBILITY:

I/We agree to be responsible for the safe return or replacement of all athletic and/or activity equipment issued by the school to the student named on the reverse side of this form.
required
I agree
Parent/Guardian Signature
required
Draw your signature in the area above, or use the saved signature button if available.
0%
Another form lovingly crafted with