Download Information Form - San Jose Unified School District

Information Form
Because of insurance and liability requirements, membership on the current WGMS sports team is required for all athletes who wish
to practice or compete with the team.
You must complete this and all other team forms before you can practice or compete with the team. Upon completion of this form, you
must give them to Coach Pappadakis before you begin your first practice or competition.
(check) XC ______ or Track_____ Year: _________
Seasons with this team: _______
Print Neatly:
Athlete’s Name _______________________________________ Athlete’s T-shirt size ______________________
Grade: ______
D.O.B. __________________ Gender_________ Athlete’s Cell Phone (____)______________
Address __________________________________________Apt #______ Home Phone (____)________________
(Street, City, Zip)
Parent/Guardian’s Name _____________________________________________Cell Phone (____)__________
Parent/Guardian’s Name ______________________________________________Cell Phone (____)_________
Email (Parent/Guardian) 1._______________________________
2.__________________________________
Email (Athlete)_____________________________________
*Day(s) you are not able to attend: ___________________________ Reason:_____________________________
*Please note that if we are able to work out a schedule so that you can do another activity, while also being a member
of this team, you must adhere to this compromise.
PERSON (OTHER THAN PARENT) TO NOTIFY IN CASE OF EMERGENCY:
Name_____________________________ Relationship: ___________________Phone (____)______________
In consideration of your allowing the above-named athlete to practice and/or compete at WGMS, I/We, intending to be legally bound for
myself/ourselves and my/our heirs, executors and administrators do hereby waive and release forever any and all rights and claims for
damages I/We may accrue against WGMS, the San Jose Unified School District, the City of Campbell/San Jose, and any other person,
organization or official affiliated with WGMS as well as their representatives, successors and assigns, for any and all injuries arising from any
participation in and/or traveling to or from WGMS outings, practices, and/or meets. In the event we cannot be reached in an emergency,
I/We hereby give permission for: Cliff Pappadakis, or any other WGMS Coach or official to authorize by his /her signature whatever medical
treatment may be considered necessary by the attending physician for my/our child.
PHOTO RELEASE
By signing at the bottom of this form I also hereby release all rights and grant full permission to WGMS coaches and staff to use any
photographs, motion pictures, recordings or any other record of my participation in this program for any legitimate purpose, including
commercial advertising.
Family Physician ____________________________________________ Phone (______)____________________
Medical Plan _________________________________________ Plan Number_____________________________
Does your child wear contact lenses/glasses ______ Hearing aid______ have Asthma_____ what medication___________________
Does your child take any medication on a regular basis _____list the specific medication _______________________________________
Does your child have any allergies _______ to what ____________________________________________________________________
Parent/Guardian’s Signature _________________________________________________Date ________________
Parent/Guardian’s Signature _________________________________________________Date ________________
Team website: http://www.sjusd.org/willow-glen-middle/teachers/pappadakis-cliff/wgms-cross-country/24098