Informed Consent Form - Lake Havasu Unified School District

ATHLETES ACKNOWLEDGMENT
AND CONSENT TO PARTICIPATION
Athlete Name:___________________________________, wishes to participate in the
sport of ______________________ in the Lake Havasu High School sports program
during the 2013/2014 season. I/We realize that there are risks involved in his/her
participation and watched the video on _____________. We watched the video entitled
“Know the Risks”. We had an opportunity to have our questions answered. I/We
understand that the risks include a full range of injuries from minor to severe. I/We
recognize the possibility that he/she might die, become paralyzed, or suffer brain damage
or other serious, permanent injury as a result of their participation in this sports program.
I/We realize that neither the protective equipment nor padding used in the sport, the
safety rules and procedures of the sport, the coaching instruction he/she receives nor the
sports medicine care he/she is provided will guarantee safety or prevent all injuries he/she
might sustain.
I/We agree to accept these risks as a condition of participation.
______________
Date
__________________________________________
Parent/Legal Guardian Signature
JOIN THE LAKE HAVASU HIGH SCHOOL BOOSTER CLUB
The Lake Havasu High School Athletic Booster Club is a non-profit organization
(Federal Tax ID #: 20-4905419) that was formed to support ALL Athletic programs at
Lake Havasu High School. Through various fundraising activities and running the snack
bar, the funds go to assist the sports programs with uniforms, equipment, and other needs
the school is unable to fund. We encourage everyone to JOIN the Athletic Booster Club
as membership is FREE. Your volunteer work can make a difference! We are always
looking for new ideas in fundraising as well as snack bar volunteers.
Student Name:
Sports Participating In:
Parent Name:
Email:
Parent Signature:
Grade:
Phone:
I will help with __________________________________________sports: or
like to give a tax deductible donation instead: $________________
Booster Club Meetings are held 2nd Monday of each month • Room K-111 (By New
GYM) • 5:30 PM
Lake Havasu High School Athletic Booster Club - PO Box 3703 • Lake Havasu City, AZ
86405