This card is to be filled out by Parent or Guardian.
Sport(s) *
Relative (or Authorized Individual)

In the event parent, family doctor, relative, or authorized individual cannot be reached, indicate your hospital preference:

IF CONTACT CANNOT BE MADE WITH ANY OF THE ABOVE, THE COACH WILL USE HIS/HER BEST JUDGMENT TO PROTECT AND ASSIST THE INJURED ATHLETE IN ACCORDANCE WITH THE FOLLOWING POLICIES: A. Caring for the athlete. B. Notifying the athlete’s parents or guardian, or if these cannot be reached, for following the directions given on the athlete’s emergency card. C. In extreme cases, getting the athlete under professional care with or without family permission. D. In cases of a need for emergency rescue aid a coach should call 911. E. Complete an accident report.


Jefferson County schools do not provide any accident or health insurance coverage for students while participating in interscholastic athletics. It is the parent/guardian’s responsibility to provide insurance coverage for his/her child.


Consent for Athletic Conditioning, Training, and Health Care Procedures

I hereby give consent for my child to participate in the school’s athletic conditioning and training program and to receive any necessary health care treatment, including first aid, diagnostic procedures and medical treatment, which may be provided by treating physicians, nurses and other healthcare providers, including Certified Athletic Trainers. The Certified Athletic Trainers have my permission to release athletic injury information about my child to the school. In the event I cannot be reached in an emergency, I hereby give permission for my child to be transported to receive necessary treatment. I understand that the Certified Athletic Trainers do research in the prevention of athletic injuries and use generalized information that does not personally identify the individual student. The Certified Athletic Trainers may use this generalized information that does not identify my child in such research.

This card is valid from August 1, 2021 - July 31, 2022.

Note: If any changes in the above information occur, a new card must be completed by the parent or guardian as soon as possible.


  1. Before an athlete is permitted to participate in the Jefferson County athletic program this permission form must be signed for each sport and on file with the school.
  2. I/ We relieve the school district of any or all liability for accidents or injuries connected in any way with the competitive athletic program.
  3. I/ We accept that it is our responsibility to provide insurance protection for the athlete while participating in competitive athletics.
  4. The School District makes available student insurance plans which offer coverage for any accident or injury resulting from participation in competitive athletics. This plan is available at your local school. (Check with your school athletics’ director.)
  5. Occasionally your son/daughter may travel to practice or a scheduled athletic event in student driven cars, if bus transportation cannot be scheduled. If you object to this procedure, please notify your high school athletics director in writing.
  6. I acknowledge that my student as a participant in athletics may be videotaped during practice or competition for purposes of review or recruitment and therefore, video may be shared with other teams or educational institutions.

NOTE: Although participation in supervised school athletic and activities programs are among the least hazardous events in which any student will engage, either in or out of school, the very nature of these school athletic and activities programs does create potential for injury. Parents should be aware that the chance of injury is present while students are participating in school activities and athletics and should understand this includes a risk of injury which may range in severity from minor, to long term catastrophic, up to and including death. Those parents who do not wish to expose their students to this possibility should not sign this permission form.

The athletic fee must be paid, and the required paperwork must be submitted, prior to the first practice. A full refund will be made to the athlete who is cut or quits before being involved in the sport through 15 calendar days. The refund must be claimed on or before the starting date of the next season. Payment plan arrangements can be made upon request.
I give Jefferson Academy permission to use my athlete's name and picture in school publications and social media posts. This includes game rosters, highlights and updates on social media and media outlets like BOCO preps and CHSAANow, and the yearbook. If there are certain exceptions, please contact the Athletic Director directly at *


(Reference JJH-E-3)

This authorization is for driving student participants to practices or scheduled athletic events or activities by private vehicle. (The district does not insure privately owned vehicles.)

Any licensed driver may be authorized to drive participating students to scheduled school activities provided the conditions outlined below are met:

  1. The vehicle being driven will be in good working condition.
  2. All students must wear seat belts.
  3. The vehicle has liability insurance coverage which meets the minimum standards of the Colorado Financial Responsibility Law.
  4. The driver is at least 17 years of age or older.
  5. The number of passengers carried shall not exceed the capacity of the vehicle and the state mandated laws.
  6. Under 18 years of age, and driving less than 6 months, there will be no one under the age of 21 as a passenger.
  7. Under 18 years of age, and driving less than one year and more than 6 months, there will be only one passenger under the age of 21. (Does not apply to a driver’s immediate family.)
  8. You cannot drive a vehicle carrying more than one passenger under age 21, unless you have held your driver license for at least one year.


I understand the driver specifications and restrictions from District Policy JJH-E-3 as listed above. I am aware that my student may be riding to practice and/or scheduled athletic/activities with an authorized 17 year or older driver who has a valid driver’s license and is operating an auto which is insured and in good working condition.

Select one option below. *


I have reviewed the High School Student Athlete handbook and acknowledge that I have read through and agree with the school’s policies including the Code of Conduct including the school’s Drug and Alcohol policies.

link to Athlete Handbook:


I fully understand that the Jefferson County schools do not provide any accident or health insurance coverage for my son/daughter while participating in interscholastic athletics. I fully understand that it is my responsibility to provide insurance coverage for my son/daughter.


Have you failed a class in the last two semesters? *
Attended Summer School
Eligibility (check all that apply, must check at least one): *
Non Attending JA Student **If student makes the team they MUST submit current Class Schedule and current Transcript. Weekly grades will be required to be sent to the Athletic Dept. every Wednesday by NOON. If grades are not received by Wednesday your student will be ineligible due to NO grades submitted the upcoming week

Student Athlete Assumption of Risk and Waiver with COVID Supplement

Attachment A, COVID Supplement

Athletes commit to:

  • Stay at least 6 feet (about 2 arms’ length) from other people.
  • Wash hands and/or use hand sanitizer frequently.
  • May wear cloth or disposable face masks as required (indoors) or recommended (outdoors); an athlete choosing to wear a mask will not be discouraged from doing so.
  • Do not touch face, eyes, nose, or mouth with hands. Sneeze into your elbow.
  • Athletes are encouraged to bring sport-specific gloves and equipment; these are not to be shared with others.
  • Do not gather in groups. Stay out of crowded places and avoid mass gathering.
  • Launder workout clothes after each workout.
  • Wait in their cars with guardians until just before the beginning of a practice, warm-up, or game, instead of forming a group.
  • Do not engage in unnecessary physical contact, such as high fives, handshakes, fist bumps, or hugs.
  • Plan on bringing enough water to get through the workout. Common water sources will not be available.
  • Limit the use of carpools or van pools. When riding in an automobile to a sports event, it is preferred that players to ride to the sports event with persons living in their same household.
  • Each coach/sponsor will escort participants to their vehicle and/or pick up areas to depart from campus/area. No gathering after workouts will be allowed.
  • Each sport will have specific disease transmission controls that coaches will share; athletes will follow that additional guidance.

Parents commit to:

  • Notify the coach if the athlete or another member of the family is experiencing COVID-19 symptoms or is determined to test positive or be presumed positive for COVID-19.
  • Athletes are to wait in their cars with guardians until just before the beginning of a practice, warm-up, or game, instead of forming a group.
  • Limit the use of carpools or van pools. When riding in an automobile to a sports event, it is preferred that players to ride to the sports event with persons living in their same household.
  • No spectators will be allowed - Parents or transportation providers will remain in their cars at all times.

*Adapted from the Student Athlete Assumption of Risk and Waiver with COVID Supplement provided by Jeffco Public Schools

On behalf of my child, I (parent/guardian) hereby acknowledge and agree that activities such as those listed above have inherent risk such as minor physical/emotional injuries like cuts, bruises, sprains; to serious physical injuries like breaks, dislocations, serious wounds, cardiovascular issues, traumatic brain injury and possibly even a risk of death. Additionally, I acknowledge that COVID risks may also be present through participation in this activity. I have sufficient knowledge of the nature and extent of the risks associated with these activities and the use of facilities and equipment associated with these activities. If I had any questions or concerns regarding possible risks, I have addressed them with the activity/program sponsor.

I further acknowledge that the risks communicated by the activity/program sponsor may not be inclusive of all the possible risks associated with (activity/school program listed below)  and that the activity/program facilitator(s) may not have anticipated all of the risks associated with the above activities.

I accept the fact that the program facilitator(s) cannot guarantee my child’s total safety since some risks in such activities are beyond their control. I fully comprehend and willingly assume the responsibilities and risks of participating in this program, as outlined in information communicated to me by the facilitator(s).

I understand that if I experience an injury/illness, including a concussion, then it is my responsibility to inform the activity/program sponsor immediately. I hereby give my consent to have my child seen by emergency medical personnel, a physician, or a nurse and treated if necessary in case of sudden illness or injury while participated in the above activity. It is understood that neither Jeffco Public Schools nor Jefferson Academy provide medical insurance for such treatment and that the cost thereof will be at my expense.

I and my child agree to follow all instructions and guidelines given by the facilitators, and to act in a safe and responsible manner toward all participants, including those set forth in attachment A to this document, COVID Supplement.

I hereby waive, release, and discharge the Jeffco Public Schools, Jefferson Academy and their/its successors, heirs, assigns, directors, officers, employees, supervisors, agents, attorneys, and representatives from any and all actions, causes of action, claims, demands, losses, damages, costs, attorney’s fees, judgements, liens or liabilities whatsoever, regarding the aforementioned activity in which I and my child have elected to voluntarily participate.
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