Chicago Cougars: Parental Concent Forms

CCYP Parental Concent Form
Parental Concent Form

Chicago Cougars Youth Program
Spring Camp
Parental Contract and Parental Consent Form
2245 W. Jackson

ONLY PARENT OR GUARDIAN CAN REGISTER CHILD AND MUST BE PRESENT DURING REGISTRATION
Legal Name of Participant (must match birth certificate)
Last _______________________________, First________________________ M.I. ___
Address_________________________________________________________________
City___________________________, State_____________, Zip___________________
Phone (____) ___________________ Alternate Phone (____) _____________________
Gender: Male_____ Female _____ D.O.B _______________________
School ____________________________________________________
Mailing Address if different from above________________________________________
City____________________________, State________, Zip_________________
Name of Parent or Guardian ________________________________________________
Relationship to athlete________________________________________________
Address if different from above_______________________________________________
City______________________________, State________, Zip______________________
Emergency Contact Information (if the parent/guardian can not be reached)
Name_____________________________________________________________________
Phone (____) _________________________ Alternate Phone (____) __________________

Parental/Guardian Code of Conduct Agreement (read and signed by parent or guardian)
I______________________________, agree that I will participate in educating and executing the policies of good conduct and sportsmanship throughout the program as a parent of a student athlete, and that I am also responsible for the behavior and correction of all inappropriate behavior in all Chicago Cougars Programs.


If you have any questions contact Ms. Buckner –Vice President CCYP or email us at chicagocougars@sbcglobal.net.

Parental Concent FormParental Concent Form

More Handouts:
  • medical Concent Form - PARENT/GUARDIAN AUTHORIZATION My child has a physical condition which requires him/her to receive medication as quickly as possible in order to avoid a medical crisis. In the interest of his/her personal well being, I hereby grant my child the authority to carry his/her medication (medication name) ______________________________ and to self-administer it as directed by the prescribing physician when needed. Condition requiring possession of medication and self-medication: ________________________________________________ The above-named child may possess and use ___________________________________________________________ by self-administration. He/she has been instructed in its proper possession and use. In granting this permission for my child to possess medication and self-medicate, I hereby absolve the Chicago Cougars, employees, parents, administrators, thereof (collectively, "Releasees"), from any liability or legal responsibility for any condition that may arise from the administration or lack of administration of such medication. Parent/Guardian Signature: __________________________________________________Date: __________________________ NOTE: A completed and signed copy of this form must be given to the camp director or health director no later than the first day of camp or on the first day that the child brings the medication to camp. Pursuant to Illinois law, please complete the following information. (Use back side, if necessary): - Medication Name____________________________________________________________________________________________ - Dosage____________________________________________________________________________________________________ - Method of administration _____________________________________________________________________________________ - Frequency and timing of Medication_____________________________________________________________________________ - Date of Prescription or Order: _________________________________________________________________________________ - Other Medical Conditions Requiring Medication: __________________________________________________________________ - Specific Recommendations for Administration: ___________________________________________________________________ - Side Effects, Contraindications and Adverse Reactions to be Observed: - Any severe adverse reactions that may occur to another child, for whom the epinephrine auto-injector or inhaler is not prescribed, should the other child receive a dose of the medication. PARENT/GUARDIAN AUTHORIZATION My child has a physical condition which requires him/her to receive medication as quickly as possible in order to avoid a medical crisis. In the interest of his/her personal well being, I hereby grant my child the authority to carry his/her medication (medication name) ______________________________ and to self-administer it as directed by the prescribing physician when needed. Condition requiring possession of medication and self-medication: ________________________________________________ The above-named child may possess and use ___________________________________________________________ by self-administration. He/she has been instructed in its proper possession and use. In granting this permission for my child to possess medication and self-medicate, I hereby absolve the Chicago Cougars, employees, parents, administrators, thereof (collectively, "Releasees"), from any liability or legal responsibility for any condition that may arise from the administration or lack of administration of such medication. Parent/Guardian Signature: __________________________________________________Date: __________________________ NOTE: A completed and signed copy of this form must be given to the camp director or health director no later than the first day of camp or on the first day that the child brings the medication to camp. Pursuant to Illinois law, please complete the following information. (Use back side, if necessary): - Medication Name____________________________________________________________________________________________ - Dosage____________________________________________________________________________________________________ - Method of administration _____________________________________________________________________________________ - Frequency and timing of Medication_____________________________________________________________________________ - Date of Prescription or Order: _________________________________________________________________________________ - Other Medical Conditions Requiring Medication: __________________________________________________________________ - Specific Recommendations for Administration: ___________________________________________________________________ - Side Effects, Contraindications and Adverse Reactions to be Observed: - Any severe adverse reactions that may occur to another child, for whom the epinephrine auto-injector or inhaler is not prescribed, should the other child receive a dose of the medication.