Weight Room Permission Form

2018 - 2019 Weight Training & Physical Conditioning Program Permission Form

STUDENT AGREEMENT: *

I hereby apply for the privilege of participation in the Weight Training and Physical Conditioning Program. I have read the attached Weight Training and Physical Conditioning Program Rules and agree to abide them.

PARENTAL CONSENT: *

I/We hereby give our permission for the above named student to participate in the Weight Training and Physical Conditioning Program.

I/We realize that participation in the Weight Training and Physical Conditioning Program involves the potential for injury even with the best instruction and equipment, and strict observance of rules. I/We acknowledge that I/we have read and understand this warning. Furthermore, I/we release the Maple Shade City School District from all liability for any injuries incurred by my/our child during or resulting from participation in the Weight Training and Physical Conditioning Program.

In the event of an injury, I/We hereby give consent for the above named student to receive any necessary healthcare treatment that may be provided by healthcare providers employed directly or through a contract by the school. In the event of a medical emergency, I hereby give consent for any treatment, diagnosis, and/or hospital care as deemed necessary by a licensed physician. This authority is granted only after a reasonable effort has been made to reach me.

PARENTS/GUARDIANS: All students are required to have a physical on file, before participating in the Weight Training and Physical Conditioning Program. The weight room is restricted to high school students only. Junior high students are not permitted to use the weight room outside of PE class.

Student Information:

Student Last Name:

Student First Name:

Student Grade:

Parent/Guardian Information:

Parent First Name:

Parent Last Name:

Parent E-mail: *

Parent Home Phone:

Parent Cell Phone: *

Parent Work Phone: *

Emergency Contact Information:

First Name: *

Last Name: *

Phone: *

E-mail: *

Known Medical Problems: *

Known Allergies:

Current Medications:

Weight Training & Physical Conditioning Program Rules

Students must have a current physical on file.
Students wait for the weight room supervisor outside of the weight room. Once he/she arrives, the locker room will be open for students to change.
Horseplay, abusive behavior, and foul and/or abusive language are prohibited.
No food or drink allowed in the weight room.
All weights must be re-racked when you are done with them.
Wipe down benches and equipment after use.
Use equipment only as it is intended.
If you are not sure about an exercise, ask for assistance.
Always have a spotter.
Proper attire is required at all times. Appropriate footwear (athletic sneakers) must be worn. Boots, “slides”, and open-toed shoes are not permitted. Shirts must be worn at all time.
You are here to exercise, not to socialize. If you are done with your workout and you have a ride home, please leave.
The weight room will be closed on Mondays because of faculty meetings.
The weight room closes at 4:30 pm. You must have a ride home. If you do not have a ride home, do not stay after school.

Failure to abide by the above rules or any other MSHS rules and regulations may result in suspension and/or dismissal from the Weight Training and Physical Conditioning Program.

The regular weight room schedule will be posted weekly and is open from 3:00 pm to 4:30 pm. Please pay attention to any announcements during the school day for any changes to this schedule.

SIGNATURE AND AUTHORIZATION

I hereby authorize that I am the legal parent of the student named in this form and that I recognize that this is my legal and binding electronic signature and that any fraud or inaccuracy will void this student's eligibility. I further understand that there are assumed risks in using the equipment in the weight room and that your child will use the equipment responsibly.

School District Student Identification Number:

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