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MEDICAL
EXAMINATION FOR STUDENT ATHLETES: APPLICATION
FOR EXEMPTION AND WAIVER OF LIABILITY |
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Dear Parent: |
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It is the policy of the Wake County Public Schools (WCPSS)
that all students participating in interscholastic athletic activity must
receive a medical examination once every 365 days by a licensed physician,
nurse practitioner or physician’s assistant. WCPSS Board Policy 6860.5. The
purpose of this examination is to ensure that the student is physically
healthy and able to participate in strenuous athletic activity. High school
athletes who wish to participate in athletics but have a religious objection
to obtaining a medical examination may seek an exemption from this
requirement. In order to apply for a religious exemption to the exam
requirement, a parent or guardian must fill out the attached application and
release form, have both notarized, and submit them to your school’s athletic
director. (You must also complete the athletic participation form, with the
exception of the physical examination portion.). The athletic director should
keep a copy of the attached and provide a copy to school administrators to be
included in the student’s records. Please feel free to call the athletic
trainer at your school withany questions. |
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R0234567:1 |
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RELEASE OF
LIABILITY |
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We, _____________________________, as parents/guardians of
_____________________, request that this student be permitted to participate
in interscholastic athletics without obtaining the required medical
examination. We understand and acknowledge that there is a risk of injury
involved in athletic participation. Neither the athletic coaches nor Wake
County Public Schools can eliminate the risk of sports injury for any
student. We understand that sports injuries may be severe and in some cases
may result in permanent disability or even death. We also understand that the
purpose of the medical examination requirement is to reduce the risk of pain
or injury for the student athlete, discern how any current health conditions
affect the student’s ability to participate in athletics and the risk of
same, and to diagnose any previously unknown conditions that may hinder the
student’s participation and/or make the student more vulnerable to injury. We freely, knowingly, and willfully accept and assume both the
risk of injury that might occur from this student’s participation in
athletics, and any increased risk of injury that may result from the lack of
a medical examination. In addition, we agree to waive any potential claims on this
student’s behalf or on our own behalf against Wake County Public Schools, its
governing board, individual board members, employees, and agents, and to
indemnify and hold harmless Wake County Public Schools, its governing board,
individual board members, employees, and agents from any and all potential
claims, liability or litigation, brought directly or on behalf of our child
for injury or loss arising from his/her participation in school athletic
programs, including any medical services that may be rendered in an
emergency. We specifically acknowledge that
should this student be injured while participating in the school athletic
program, he or she will be assessed for injuries and treated as required,
including but not limited to being transported to a hospital. ___________________________________________ Date
_________________________ ___________________________________________
Date_________________________ ___________________________________________ Date
_________________________ Student Signature (if 18 or older) [Space for notary] |
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R0234567:1 |
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APPLICATION
FOR RELIGIOUS EXEMPTION FROM MEDICAL EXAM REQUIREMENT
FOR ATHLETIC PARTICIPATION |
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In order for Wake County Public Schools to consider your
application for a religious exemption to the medical examination requirement,
please answer the following questions in the space provided. Additional
sheets may be attached if necessary. |
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1. Please provide a brief statement of your religious beliefs
and denomination, if applicable, and why these religious beliefs prevent your
student from receiving a medical examination. |
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2. Please provide information on any and all existing medical
conditions of your student of which you are aware. NOTE: If you become aware
of additional or new medical conditions after completion of this form, please
immediately provide this information to school administrators and coaches in
writing. |
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3. Please provide any information on any health, life,
liability, or accident insurance policies covering this student. |
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I attest that the information provided above is true to the
best of my knowledge. __________________________________ Date
___________________________ |
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[Notary] |
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R0234567:1 |