Example: bachelor of science

Alt Year Permit Card 8.5x11 web

WISCONSININTERSCHOLASTICATHLETICASSOCIAT IONALTERNATEYEARATHLETICPERMITCARDSCHOOL YEAR20_____-20_____NAME __ _____ ____ ___ __ __ _____ __ __ __ _____ __ GRADE _____ _____DATE OF BI RT H__ __ _____LastFi rstMid dle Ini tialPr ese nt Address _____ __ __ __ __ _____ __ __ _____ ____ _____Telephon e__ _____ __ __ ___ _____ _____ ____Parent s' Pl ace ofEmpl oyme nt __ __ _____ ____ ___ _____ ___ _____ __ __ _____Fam ilyPhysi cian _____ __ __ ___ __ _____ __ __ ____ ___ _____Family Dentist _____ ___ __ _____ __ __ _____ _____ _Name of Privat eInsuran ce Carri er _____ _____ _____ ____ _____ _____ Tel ephone __ ____ ___ __ __ ___ ___ _____ _____Su bscr iber Member Name (Pri ma ry Insured) ___ __ __ _____ ___ ____ _____ ___ _____ __ __ _____1.

wisconsin interscholastic athletic association alternate year athletic permit card school year 20_____ - 20_____ name_____ grade_____ dateofbirth_____

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  Year, Athletic, Association, Wisconsin, Alternate, Interscholastic, Wisconsin interscholastic athletic association alternate year

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Transcription of Alt Year Permit Card 8.5x11 web

1 WISCONSININTERSCHOLASTICATHLETICASSOCIAT IONALTERNATEYEARATHLETICPERMITCARDSCHOOL YEAR20_____-20_____NAME __ _____ ____ ___ __ __ _____ __ __ __ _____ __ GRADE _____ _____DATE OF BI RT H__ __ _____LastFi rstMid dle Ini tialPr ese nt Address _____ __ __ __ __ _____ __ __ _____ ____ _____Telephon e__ _____ __ __ ___ _____ _____ ____Parent s' Pl ace ofEmpl oyme nt __ __ _____ ____ ___ _____ ___ _____ __ __ _____Fam ilyPhysi cian _____ __ __ ___ __ _____ __ __ ____ ___ _____Family Dentist _____ ___ __ _____ __ __ _____ _____ _Name of Privat eInsuran ce Carri er _____ _____ _____ ____ _____ _____ Tel ephone __ ____ ___ __ __ ___ ___ _____ _____Su bscr iber Member Name (Pri ma ry Insured) ___ __ __ _____ ___ ____ _____ ___ _____ __ __ _____1.

2 Ihere by giv emy pe rmissi on fortheab ove named stu den tto pract ice and co mpete an drepresent thesch ool in WIAA approve Ial so at test tothefact tha tthe above nam edstude nt hasha dnoinjury orillness ser ious eno ugh to warrant ame dical eval uati onpriortoparticip ating this sc hool Purs uant tothe requ irem en ts oftheHealt hInsura nc ePort abilit yand Accou ntabili ty Act of 1996 an dthe regula tions promu lga tedthere un de r(co llectiv ely known as HIPAA ) ,Iauth or -izehealt hcare pro vider sof thest ud ent namedabove, includin gem ergency medica lperso nn el and othe rsimilarl ytrainedprofessi onals that ma ybeat ten din ganinte rschola stic eventor pract ice, to dis cl os e/ exch ange essentia lme di cal inform ation regard ingthe inj ury andtre atment ofthisst ude nttoappropriate scho oldi strict personn el su ch as bu tnot lim ite dto:Princ ipal, athletic Di rector, athletic Trainer ,Te amPhys ician ,Te amCoa ch, Adm ini st rat ive Assi stantto theAt hlet icDire ctor an d/orother pro fessi onal heal th care provid ers, forpurposesof tre at ment, eme rge nc ycare an dinju ry rec ord-keep ing.

3 4. It isrecommendedtha tinf orma tion regard ing your chil d s alle rgies and prescribed medication be mad eavai REN T: Ifthere is an yqu es tio ntha tthis stude ntmay not bequa lified for athletic comp etition witho ut, at least, apartial re-evalu at ion, co ntact your medi cal adv iso rbe for esig nin gcar Date _____WISCONSININTERSCHOLASTICATHLETICASS OCIATIONALTERNATEYEARATHLETICPERMITCARDS CHOOLYEAR20_____-20_____NAME __ _____ ____ ___ __ __ _____ __ __ __ _____ __ GRADE _____ _____DATE OF BI RT H__ __ _____LastFi rstMid dle Ini tialPr ese nt Address _____ __ __ __ __ _____ __ __ _____ ____ _____Telephon e__ _____ __ __ ___ _____ _____ ____Pa rent s' Pl ace ofEmpl oyme nt __ __ _____ ____ ___ _____ ___ _____ __ __ _____Fam ilyPhysi cian _____ __ __ ___ __ _____ __ __ ____ ___ _____Family Dentist _____ ___ __ _____ __ __ _____ _____ _Na me of Privat eInsuran ce Carri er _____ _____ _____ ____ _____ _____ Tel ephone __ ____

4 ___ __ __ ___ ___ _____ _____Su bscr iber Member Name (Pri ma ry Insured) ___ __ __ _____ ___ ____ _____ ___ _____ __ __ _____1. Ihere by giv emy pe rmissi on fortheab ove named stu den tto pract ice and co mpete an drepresent thesch ool in WIAA approve Ial so at test tothefact tha tthe above nam edstude nt hasha dnoinjury orillness ser ious eno ugh to warrant ame dical eval uati onpriortoparticip ating this sc hool Purs uant tothe requ irem en ts oftheHealt hInsura nc ePort abilit yand Accou ntabili ty Act of 1996 an dthe regula tions promu lga tedthere un de r(co llectiv ely known as HIPAA ) ,Iauth or -izehealt hcare pro vider sof thest ud ent namedabove, includin gem ergency medica lperso nn el and othe rsimilarl ytrainedprofessi onals that ma ybeat ten din ganinte rschola stic eventor pract ice, to dis cl os e/ exch ange essentia lme di cal inform ation regard ingthe inj ury andtre atment ofthisst ude nttoappropriate scho oldi strict personn el su ch as bu tnot lim ite dto:Pr inc ipal, athletic Di rector, athletic Trainer ,Te amPhys ician ,Te amCoa ch, Adm ini st rat ive Assi stantto theAt hlet icDire ctor an d/orother pro fessi onal heal th care provid ers, forpurposesof tre at ment, eme rge nc ycare an dinju ry rec ord-keep ing.

5 4. It isrecommendedtha tinf orma tion regard ing your chil d s alle rgies and prescribed medication be mad eavai REN T: Ifthere is an yqu es tio ntha tthis stude ntmay not bequa lified for athletic comp etition witho ut, at least, apartial re-evalu at ion, co ntact your medi cal adv iso rbe for esig nin gcar Date _____WISCONSININTERSCHOLASTICATHLETICASS OCIATIONALTERNATEYEARATHLETICPERMITCARDS CHOOLYEAR20_____-20_____NA ME _____ ____ __ __ __ __ ___ _____ _____GRADE ____ _____DATE OFBIRT H___ ___ _____LastFi rstMiddle InitialPr esen tAddress __ ____ ____ __ _____ _____Telephone __ __ __ ___ __ ___ __ _____Par en ts' Place of Emp loyme nt ___ _____ _____ __ __ ___ __ __ _____Fa mi lyPhysici an __ ____ ___ __ __ _____ ___ _____Family Dentist _____ ____ ___ __ _____Nam eof Privat eInsur an ce Car rier ____ _____ _____Telephone ___ __ ___ __ __ ___ _____Sub scr iber Mem ber Name (Pri ma ry Insured) _____ _____ __ __ ___ __ _____1.

6 Ihereby give my pe rmission for the abov enam ed stud ent toprac tic ean dcom pete and represe nt the scho ol in WIAA app roved spo Ials oattest to the facttha tthe abov enam ed st uden tha shad no injury or illness seriou senou gh to warran tamed ical evalu at ionpri or toparticipat ing this school Pursuant to the req ui reme nt softhe He alth Ins uran ce Porta bility an dAccoun tability Act of 1996 and the reg ulation spro mulga tedthere und er (collectivelyknown as HIPAA ), Iauthor -ize healt hcare pr ov ider sof thestu de nt na me dabo ve ,inc ludi ng em erg ency me dica lperson nel and other simila rly train ed pro fessio na ls tha tmay be att ending an interscholasticev entor prac tice, to discl ose /excha ng eessen tial med ical info rma tion regardin gtheinjury and treatme nt ofthis studen tto app ropri at esch oo ldistri ct pe rsonnel such as but not limited to.

7 Pri ncipal , athletic Direc tor, At hle ticTrai ner, Team Phy sic ian, Tea mCo ac h, Admin istrative Assi stant to the Athle ticDir ector and/ or otherprofessio nal heal thcare prov ide rs,for purposesof treat ment, emer ge nc ycare and injury rec ord-k eep Itis recommendedthat inf orm at ion reg ardin gyo ur child sallerg ies and prescr ibed med ica tio nbemade availa RE NT: If there is an yque stio nthat this stu dent may no tbe quali fied for athletic co mpe titio nwithou t, at least, apartia lre-eva luation ,co nt act your medical advisor before signing Date _____


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