Athletic Participation Form

FOR OFFICE USE ONLY Athletic Card Number _________________

SCHOOL YEAR_____________ ASB___________ PHYS DATE________________ STUDENT #_____________

FALL: FB FP GSOC VB GO GSW CC BTE CHEER BWP

WINTER: BBB GBB GYMN WR BSW Dance Cheer

SPRING: TR BB VB BSOC FP GTE GWP

AUBURN SCHOOL DISTRICT ATHLETIC PARTICIPATION FORM

NAME________________________________________M____F____GRADE_____AGE______BIRTHDATE______________

HOME ADDRESS_____________________________________________ HOME PHONE: ____________________________

CITY/STATE/ZIP________________________________________ PARENT’S CELL PHONE: ________________________

PARENT CONSENT/ASSUMPTION OF RISK

We hereby give our consent for our son/daughter to engage in interscholastic activities provided by the Auburn School District unless disapproved by the examining physician. We also give our consent for the student to accompany the team to other school venues. We will comply with and support the participation rules of the Auburn School District. This application to compete in interscholastic athletics in the Auburn School District #408 is made with the understanding that eligibility rules and regulations of the state association have not been violated. Competitive athletics is a voluntary extra-curricular activity and participation may result in severe injury, including paralysis or death. No amount of reasonable supervision or training can completely eliminate the risk of possible injury.

AS A CONDITION OF PARTICIPATION IN ATHLETICS, WE ACKNOWLEDGE THAT WE HAVE READ AND UNDERSTAND THIS WARNING STATEMENT.

Parent/Guardian Signature __________________________________ Date _______________________

MANDATORY ACCIDENT INSURANCE (Check One)

_________ My son/daughter is currently enrolled in the Student Accident Insurance Program offered through the Auburn School District. Information regarding this plan is available through your child’s school office. (OFFICE CONFIRMATION REGARDING PURCHASE)

_________ My son/daughter is covered by the insurance listed below and I will continue to keep it in force throughout the sports season. If there are any changes in this status, I will contact the school to inform them of changes in insurance. The high school principal or designee is authorized to contact the company named below to verify coverage limitations. I accept full responsibility for the cost of treatment of any injury that my son/daughter may suffer while taking part in the program.

Name of Insurance Company: _________________________________________________________

Policy or Group #: ___________________________________________________________________

Parent/Guardian Signature ________________________________________ Date_________________

PERMISSION FOR MEDICAL TREATMENT

In the event of an emergency requiring medical attention, we hereby grant permission to a physician or other hospital personnel designated by the Auburn School District's coaching staff to attend our son/daughter. We expect every effort will be made to contact us in order to receive our specific authorization before any treatment or hospitalization is undertaken.

Parent/Guardian Signature________________________________________ Date _________________

MEDICAL EVALUATION REPORT (ALL INCOMING 6^TH AND 9^TH GRADERS ARE REQUIRED TO HAVE A NEW PHYSICAL)

Auburn School District policy requires that:

*** A current physical examination is completed prior to participation at the high school level (grades 9-12) and must be dated AFTER JUNE 1^st, for the upcoming school year.

*** A current physical examination is completed prior to participation at the middle school level (grades 6-8) and must be dated AFTER JULY 1^st, for the upcoming school year.

*** Physicals may be valid up to 24 months from the date of the examination if all conditions are met.

Physical expiration dates must extend beyond the respective WIAA season ending date.

*** Expiration dates occurring within a sport season shall require a new examination prior to that season.

PHYSICIAN’S REPORT

DATE OF PHYSICAL EXAMINATION: ______________________

Clearance for participation in Auburn School District athletics: Yes _____ No _____

Physical limitations and/or recommendations: ________________________________________________

_____________________________________________________________________________________

To be filled out for middle school wrestlers:

If _____________________________ competes in wrestling, the minimum weight should be no less than ___________ pounds.

____________________________________________ _________________________ _____________________________

Medical Examiner’s name (Print or type) Phone number Clinic Address

________________________________________________________________________ _____________________________

Medical Examiner’s signature Date

ATHLETIC ELIGIBILITY (High School only)

Please accurately answer the following questions pertaining to athletic eligibility. It is extremely important to give accurate information.

Yes No

________ ________ The above student is under 20 years of age.

________ ________ The above student resides within the boundaries of the Auburn School District

________ ________ The above student resides with his/her parents/legal guardians.

________ ________ The above student was in attendance in school at least 15 weeks of the previous semester.

________ ________ The above student passed 4 classes during the previous semester.

________ ________ The above student is presently enrolled in the Auburn School District a minimum of 4 full-credit classes.

Is the student ___Running Start ___Home Schooled ___ Alternative School ___Other ____________________________

Year entered seventh (7^th) grade _______________________ Year entered ninth (9^th) grade ______________________

School attended last year: _______________________________________ Dates attended: ____________ to __________

Student Signature ________________________________________________ Date _______________________

Parent/Guardian Signature ____________________________________________________ Date ______________