Items marked with an asterisk (*) are required.

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Form Requirement(s)

  • Can upload: Student
  • Can upload: Parent
  • Can upload: Staff

  • Required for Athlete Overall Approval.
  • Student Athlete Signature Required.
  • Parent Signature Required.
  • Staff Signature Required.
  • Use of the Previous Year Form is allowed as long as it is not expired.

  • Auto Approval: Auto-Approve enabled with the EXCEPTION of all Uploaded forms and History Forms with Yes answers.

This form must be completed not earlier than six weeks prior to the first Practice day of the sport(s) in the sports season(s) identified herein by the parent/guardian of any student who is seeking to participate in Practices, Inter-School Practices, Scrimmages, and/or Contests in all subsequent sport seasons in the same school year. The Principal, or the Principal’s designee, of the herein named student’s school must review the SUPPLEMENTAL HEALTH HISTORY.

If any SUPPLEMENTAL HEALTH HISTORY questions are either checked yes or circled, the herein named student shall submit a completed Section 8, Re-Certification by Licensed Physician of Medicine or Osteopathic Medicine, to the Principal, or Principal’s designee, of the student’s school.

Winter Sport(s)
CHANGES TO PERSONAL INFORMATION

In the spaces below, identify any changes to the Personal Information set forth in the original Section 1: PERSONAL AND EMERGENCY INFORMATION

CHANGES TO EMERGENCY INFORMATION

In the spaces below, identify any changes to the Emergency Information set forth in the original Section 1: PERSONAL AND EMERGENCY INFORMATION

SUPPLEMENTAL HEALTH HISTORY Yes No
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I hereby certify that to the best of my knowledge all of the information herein is true and complete.


Signatures


Student Athlete


Print Name:

Signature:

Date:

Parent / Guardian


Print Name:

Signature:

Date: