MSAA INTERSCHOLASTIC SPORTS
PARENTAL PERMISSION AND INSURANCE STATEMENT
TO: ___________________________________________________, Principal
___________________________________________________ School
PART I
I, ____________________________________________(Parent or Guardian), hereby grant permission
for my son/daughter _________________________________, (Birthdate: Mo._____________
Day_____________ Year____________), to participate in interscholastic sports during the
_________________school year.
(Please circle the sports in which your son/daughter MAY NOT participate.)
Soccer, Cross Country, Golf, Basketball, Flag Football, Volleyball, Track
My son/daughter has been examined by a physician and is physically qualified to participate in the
sports stated above.
The original physical is attached with doctor’s stamp of approval.
I authorize my child to accompany the school team, of which he or she is a member, on any of its
local or out of town trips; also: I authorize the school to obtain, through a physician of its own
choice, any emergency medical care that may become reasonably necessary for my child as a result of
game participation.
We have accident insurance with ____________________________________ (Name of
Insurance Company) which will cover my son/daughter in the event of an interscholastic
sport injury as required by School Board Policy #5304. I will assume responsibility for
payment of doctor and hospital bills for treatment of any injury my son/daughter might
suffer while participating in athletic activities. If any change occurs in this policy, it is the
responsibility of the parent to notify the School Principal or Athletic Director.
A photocopy of the front of the Insurer’s policy card is attached.
(Signed)________________________________________
Parent or Guardian
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NOTARIZATION
*NOTE* STATE OF FLORIDA
COUNTY OF _________________________________
Sworn to and subscribed before me
A COPY OF VALID
INSURANCE I.D. CARD this ___________day of ____________, 20___________
MUST BE ATTACHED TO
THIS FORM _______________________________________________
Notary Public
My Commission Expires: ________________________
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PART II
INSTRUCTIONS TO PARENT OR GUARDIAN
1. Complete, sign and have the document notarized.
2. Attach proof of Insurance AND proof of Student Physical WITH Doctor’s Stamp.
