MONTGOMERY COUNTY PUBLIC SCHOOLS
INTRAMURAL PROGRAM
PARENT/GUARDIAN PERMISSION FORM
My child _____________________________________ in Grade ______ has my permission to participate in
(Please print student’s first and last name)
the following after-school intramural activity program at Kingsview Middle School. This program will
be held on Tuesday, and/or Wednesday, and/or Thursday from 3:05 – 4:25 p.m.
I give permission for my child to participate in the following intramural program(s):
_________
Flag Football (Fall)
_________
Street Hockey (Spring)
_________
Indoor Basketball (Spring)
*Other intramurals may be offered during the year and a separate permission form will be available.
I have indicated below the manner in which my child will be transported home:
_________
Walk
_________
I will pick up my child
_________
Activity bus (available for students who normally ride a bus to school)
_________
Can go home with __________________________________________________
_________
Other: ____________________________________________________________
It is recommended that each participant be covered by medical insurance. Forms for purchasing the optional
school insurance can be obtained at the beginning of each school year.
Please check one of the following:
_________
The above named student is covered by medical insurance.
_________
The above student is NOT covered by medical insurance.
_________
I wish to purchase the optional school insurance.
Parent/Guardian Name: _______________________________________
Phone Number: _______________
Parent/Guardian Signature: ____________________________________
Date: _______________________
Parent/Guardian Name: _______________________________________
Phone Number: _______________
Parent/Guardian Signature: ____________________________________
Date: _______________________
NOTE: When parents have legal joint custody, both parents must sign.
Please return this permission form and the medical card (on the back) to your physical education teacher.