Activity Permission Form

It is my desire to allow my student-athlete at Starkville Academy to participate in school sponsored sports, band, or other activities for the current school year. I understand that occasionally injuries occur in these activities and that Starkville Academy assumes no risk or responsibility for these injuries. While Starkville Academy is not an agency for any company selling student accident policies, the school will make available a low cost insurance policy for its students. I release Starkville Academy, the Board of Directors, the Head of School, coaches and teachers from all responsibility in case of injury.

Athlete's first name *

Middle initial

Last name *

Athlete's grade (upcoming school year) *

Parent (or guardian) digital signature *

Parent's phone number *

Today's date * +

Policy# *

Name of insurance company *

Address of insurance company *

If group policy, give employer

The above named participant is not covered by hospitalization insurance.

I have uploaded my signed copy of the MAIS concussion form.

Date of Physical: +

First page (front)

second page (back) if needed

third page if needed

I have uploaded my signed copy of my athlete's PPE acquired by a licensed physician.