Form – Parent Consent and Emergency Information 2017-02-16T23:26:34+00:00

Parent Consent and Emergency Information

Please fill out the form below.


  • My signature below indicates my permission for my scholar, who is named below, to participate in after school sports/activities at Heritage Academy. My signature also indicates that I have read and approve the medical treatment authorization.
  • EMERGENCY INFORMATION
  • In an emergency, if the parents cannot be reached, please notify:
  • MEDICAL TREATMENT AUTHORIZATION
  • In the event of illness or injury occurring to my child while participating in this activity, I hereby give my consent for medical or dental care deemed necessary by the attending health care provider or dentist. My child may be examined and any necessary procedures (medical, dental, or surgical), anesthesia or diagnostic procedures (lab or x-ray) may be performed under the supervision of a member of the hospital or medical office staff furnishing such services.
  • I understand that, in the event of other than minor illness or injury, reasonable effort will be made to contact me.
  • I understand that there is inherent risk in many activities, and I hold Heritage Academy harmless and not liable for injury or accident, which may occur in the course of such activities. I willingly and ultimately assume the risk of such injury or accident.
  • This field is for validation purposes and should be left unchanged.
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