| Document Date: 2014-07-09 15:18:56
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City Parkersburg / / Facility Staunton Turnpike / / IndustryTerm football insurance coverage / student accident insurance / / Organization WEST VIRGINIA SECONDARY SCHOOL ACTIVITIES COMMISSION / School Administration Office / Middle School / / Position athletic director / physician / Family Dentist / private physician / MS athlete / team physician / team member / Family Physician / STUDENT-ATHLETE / THE STUDENT-ATHLETE / legal guardian/custodian / ATHLETIC PARTICIPATION/PARENTAL CONSENT/PHYSICIAN / designated representative / MD/DO/DC/Advanced Registered Nurse Practitioner/Physicians Assistant / athletic team Participation/Parent Consent/Physician / Athlete / / ProvinceOrState West Virginia / / Region WEST VIRGINIA / / Technology Sports Medicine / /
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WEST VIRGINIA SECONDARY SCHOOL ACTIVITIES COMMISSION 2875 Staunton Turnpike - Parkersburg, WV[removed]June[removed]ATHLETIC PARTICIPATION/PARENTAL CONSENT/PHYSICIAN’S CERTIFICATE FORM