ACKNOWLEDGEMENT OF RECEIPT FORM 2019-2020

This signed receipt acknowledges receipt of the 2019-2020 Student-Parent Handbook of Wisner-Pilger Jr/Sr High School. It is
understood that the handbook contains student conduct and discipline rules and information about Safe and Drug-Free Schools and
that the undersigned, as student, agrees to follow such conduct and discipline rules. This notice is being provided to you pursuant
to P.L. 101-226 and 34 C.F.R. part 86, both federal legal requirements for the District to obtain any financial assistance.
This receipt also serves to acknowledge that it is understood that the District’s policies of non-discrimination and equity, and that
specific complaint and grievance procedures exist in the handbook which should be used to respond to harassment or discrimination.
AVAILABILITY OF HANDBOOKS The 2019-2020 Student-Parent Handbook of Wisner-Pilger Public Schools is available on the
internet at www.wisnerpilger.org. If you prefer a paper copy of the Student-Parent Handbook, please contact the school office at
your earliest convenience.

Signature of Student Date

Signature of Parent/Guardian Date

PERMISSION TO ADMINISTER NON-ASPIRIN PAIN RELIEF MEDICATION

I give my permission for adults at Wisner-Pilger Jr/Sr High School to administer non-aspirin pain relief medication to

as needed, not to exceed 2 tablets every 4 hours. It may be

(Student Name)
administered for the following symptoms: headache, menstrual cramps, muscle aches, dental pain, flu-like symptoms, and
other similar complaints.

Signature of Parent/Guardian Date

PERMISSION TO ADMINISTER CALCIUM-BASED ANTACID

I give my permission for adults at Wisner-Pilger Jr/Sr High School to administer calcium-based antacid medication to

as needed.
(Student Name)
Signature of Parent/Guardian Date

EMERGENCY CONTACT and MAILING INFORMATION

Father/Guardian__________________________ Work Phone #:____________________ Cell Phone #:___________________

Mother/Guardian__________________________ Work Phone #:____________________ Cell Phone #:___________________

Home Phone #:___________________________ E-Mail Address_________________________________________________

Parent/Guardian Mailing Address:___________________________________________________________________________

In the case of an emergency and the school could not contact the parents, the school should contact:
.
at at
(person) (phone number) (person) (phone number)

AUTOMATED ALERT SYSTEM CONTACT INFORMATION

(This is for the automated phone system that will contact you in case of school cancellations or other important information- # ’s need to be updated each year)
Voice Calls Voice Calls and/or Text Messages
Telephone Contact #1:____________________________ Primary Mobile#:_________________________________
Telephone Contact #2:____________________________ Secondary Mobile#:_______________________________
E-Mail Addresses
E-mail Address #1:_______________________________ E-Mail Address #2:________________________________

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 To be completed for students Student and Parent Consent Form
participating in any NSAA
activities.

Wisner-Pilger Jr. Sr. High School 2019-2020

Name of Student:
____________________________________________________________________
Date of Birth: ____________________ Place of Birth: _______________________________________
The undersigned(s) are the Student and the parent(s), guardian(s), or person(s) in charge of the above named Student and are
collectively referred to as "Parent”.

The Parent and Student hereby:

(1) Understand and agree that participation in NSAA sponsored activities is voluntary on the part of the Student and is a privilege;

(2) Understand and agree that (a) by this Consent Form the NSAA has provided to the Parent and Student of the existence of potential dangers
associated with athletic participation; (b) participation in any athletic activity may involve injury of some type; (c) the severity of such injury can range
from minor cuts, bruises, sprains, and muscle strains to more serious injuries to the body’s bones, joints, ligaments, tendons, or muscles, to
catastrophic injuries to the head, neck and spinal cord, and on rare occasions, injuries so severe as to result in total disability, paralysis and death;
and, (d) even the best coaching, the use of the best protective equipment and strict observance of rules, injuries are still a possibility;

(3) Consent and agree to participation of the Student in NSAA activities subject to all NSAA by-laws and rules interpretations for participation in
NSAA sponsored activities, and the activities rules of the NSAA member school for which the Student is participating; and,

(4) Consent and agree to (a) the disclosure by the Member School at which the Student is enrolled to the NSAA, and subsequent disclosure by
the NSAA, of information regarding the Student, including the student’s name, address, telephone listing, electronic mail address,
photograph, date of and place of birth, major fields of study, dates of attendance, grade level, enrollment status (e.g., full-time or part-time),
participation in officially recognized activities and sports, weight and height of as a member of athletic teams, degrees, honors and awards
received, statistics regarding performance, records or documentation related to eligibility for NSAA sponsored activities, medical records, and
any other information related to the Student’s participation in NSAA sponsored activities; and, (b) the Student being photographed, video
recorded, audio taped, or recorded by any other means while participating in NSAA activities and contests, consent to and waive any privacy
rights with regard to the display of such recordings, and waive any claims of ownership or other rights with regard to such photographs or
recordings or to the broadcast, sale or display of such photographs or recordings.

(5) Consent and agree to authorize licensed sports injury personnel to evaluate and treat any injury or illness that occurs during the student’s
participation in NSAA activities. This includes all reasonable and necessary preventive care, treatment and rehabilitation for these injuries.
This would also include transportation of the student to a medical facility if necessary. Such licensed sports injury personnel are independent
providers and are not employed by the NSAA.

(6) Acknowledge that Parents are obligated to pay for professional medical and/or related services; the NSAA shall not be liable for payment of
such services. We give permission to any and all of the Student’s health care providers and the NSAA and its employees, staff, agents, and
consultants to release and discuss all records and information about the Student including otherwise confidential medical information and
records. We understand that this release has been requested and may be used for the purpose of determining eligibility pertaining to
activities participation, fitness, injury, injury status, or emergency.
I acknowledge that I have read paragraphs (1) through (6) above, understand and agree to the terms thereof, including the warning of
potential risk of injury inherent in participation in athletic activities.

______________________________________ _____________________________________ ___________________

Name of Student [Print Name] Student Signature Date
(I am)(We are) the Student’s [circle appropriate choice] (Parent) (Guardian). (I)(We) acknowledge that (I)(We) have read paragraphs (1) through
(6) above, understand and agree to the terms thereof, including the warning of potential risk of injury inherent in participation in athletic
activities. Having read the warning in paragraph (2) above and understanding the potential risk of injury to my Student, (I)(we) hereby give (my)
(our) permission for ___________________________[insert student name] to practice and compete for the above named high school in
activities approved by the NSAA, except those crossed out below:
Wrestling Golf Softball Play Production Basketball Swimming/Diving

Track Football Speech Cross Country Music Volleyball

____________________________________ ____________________________________ _________________

Parent [Print Name] Parent Signature Date

Revised July 2019

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