Ezra Academy
2015-2016
Tennis Program Permission Slip
My child
has my permission to stay after school and participate in the Tennis
Program. I understand that practice is from 3:15 to 5:00 PM and it is expected that my studentathlete will be promptly picked up after practice.
The schedule will be posted on the Ezra Academy website calendar. Cancellations will be
posted on the Ezra Academy website by 1:30 pm.
Signature:
Date:
If you have any questions, please contact Cathy Sutherland @ 203-389-5500 Ext: 116 or
csutherland@ezraacademyct.org .
Medical Authorization for Athletics 2015-2016
75 Rimmon Road
Woodbridge, CT 06524
(203)-389-5500
Part 1: to be completed by parent:
I hearby give
permission to participate in the Ezra Academy Sports program
Name of Athlete
during the 2015-2016 academic year. My child has the following:
Allergies Yes
Medication Yes
No
No
Medical Condition/Treatment Yes
No
If yes, please explain:
Do you have any concerns about your child that the coach should be aware of?
I understand that it is my responsibility to report to the School Nurse and the Coach any and all medical
or social conditions, which may affect the well being of my child athlete.
Date____________Parent/Guardian signature__________________________________________
Part 2: to be completed by physician:
Physician Practice Stamp Here:
______________is cleared medically to participate in extracurricular sports for the 2015-2016 school
year.
Name of Athlete
Physician’s Signature:___________________________________Date:_______________________