FORM A
Revised 10/14/15
Everett Public Schools
Athletic Eligibility Questionnaire
A new form must be completed at the start of each sports season.
Student Name
| Student#
| Grade
| DOB
| Age
| Gender
| Sport
|
Current Address:
1. What school/District did you attend last trimester/semester? School District
(Private MS athletes must play at the same Everett school in 7th AND 8th grade. Requests to change must be made in writing to the District Athletic Director.)
2. Are you a new student to Everett Public Schools this year?
qY
es qNo
3. Do you and your parent(s)/guardian live in your school’s attendance area?
q
Yes
q
No
If no, where do you live?
4. Are you living with your parent(s)/guardian?
q
Yes
q
No
5. Will you remain enrolled in at least five (5) HS classes (12 Running Start credits) or
qY
es qNo
six (6) MS classes throughout the season?
6. Are you a running start, alternative school or home school student?
qY
es qNo
7. Were you enrolled as a full-time student & did you pass all your classes last trimester/semester?
q
Yes
q
No
8. Are you a foreign exchange student?
q
Yes
q
No
9. Have you repeated any grade or withdrawn from school at any time since the start of 7th grade?
q
Yes
q
No
If yes, what grade was repeated?
10. HS: Will you be under the age of 20 on the first day of the season?
qY
es qNo
MS: Were you under the age of 15 prior to June 1 of the previous school year?
11. Did you experience a significant injury during a school or non-school activity within the last year
q
Yes
q
No
(concussion, surgery, broken bone, etc.)? If yes, explain.
False information may result in the loss of athletic eligibility and the forfeiture of team games.
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FERPA RELEASE:
q
Yes
q
No I give permission for this student-athlete to appear in any publications for the purpose of telling of activities happening in the Everett School District. I understand that these publications might include school informational or promotional brochures, pictures, newspaper articles and/or newsletters relating to school activities.
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LIMITED HIPAA RELEASE:
q
Yes
q
No I hereby give permission for the staff at my child’s school, including its nursing staff, to share relevant medical information with the District’s Athletic Department, including athletic coaches and trainers. I understand that should any questions arise about a past or present medical issue potentially affecting my child’s eligibility for athletics or activities in this District, and I refuse to provide additional medical information if requested, my child may be deemed ineligible to participate in District athletics or activities until such information is provided
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MEDICAL INSURANCE/WAIVER (Check one box)
q
I have purchased athletic insurance offered through the school district. (Date purchased: )
q
I have my own insurance with policy # and wish to waive the schools' athletic insurance.
q
I cannot afford athletic insurance. Contact your coach, principal or athletic coordinator for an application for the Athletic Department to determine if there is a need for athletic insurance to be purchased for you.
Medical expenses not covered by insurance are the responsibility of the family.
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ATHLETIC FEE ($100/HS or $40/MS, payable to Everett School District) (Check one box)
q
My user fee will be paid to the ASB office prior to the first contest.
q
Due to financial hardship, I request a reduced fee or payment plan for my fee.
(Contact your school’s athletic coordinator)
q
I qualify for free/reduced lunch and request a waiver of the user fee. I understand that this will be verified through the food and nutrition department.
(Fee will be added to student’s account if not paid or other arrangements made.)
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Side 1 of 2
CONCUSSION AND SUDDEN CARDIAC ARREST INFORMATION ACKNOWLEDGEMENT
My parent/guardian and I have reviewed the Concussion and Sudden Cardiac Arrest Information Sheets. Contact a physician if there are any medical concerns.
q
We have reviewed the Concussion and Sudden Cardiac Arrest Information Sheet.
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PARENT/STUDENT/COACH COMMUNICATION
My parent/guardian and I agree to follow all protocol listed within the document. Parents/Guardians will encourage their athlete to discuss athletic concerns with his/her coach before intervening. Appointments will be scheduled with coaches to discuss concerns rather than discuss them at practices or games.
q
W
e
accept the protocol. q We do NOT accept the protocol.
(Failure to accept the conditions of this document will result in immediate ineligibility.)
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PARENT/GUAR
DIAN SPORTSMANSHIP ACKNOWLEDGEMENT
I understand that the players, coaches and officials involved in athletics work hard to prepare for contests and my support and understanding are expected. It is a privilege, not a right, that I am admitted into contests in order to support the spirit of athletics and the endeavors of the players. I am expected to demonstrate respect and class for the players, coaches, fellow fans and officials by cheering great plays, accepting the calls by the officials and supporting everyone involved in the contest no matter what team they are on. If I fail to act in a respectful way, I may be asked to leave contests. I am expected to win with class and lose with dignity just like the athletes.
q
I
accept my role in sportsmanship. q I do NOT accept my role in sportsmanship.
(Failure to accept your role in sportsmanship will result in immediate ineligibility.)
STUDENT-ATHLETE SPORTSMANSHIP ACKNOWLEDGEMENT
I am expected to treat my teammates, opponents, coaches, and officials with the same respect I expect from them. I will act with sportsmanship, play by the rules, play hard, have fun, accept the calls of officials, win with class and lose with dignity. I will represent my school and my team with excellence. I understand that participation in athletics is a privilege, not a right.
q
I
accept my role in sportsmanship. q I do NOT accept my role in sportsmanship.
(Failure to accept your role in sportsmanship will result in immediate ineligibility.)
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ATHLETIC CODE ACKNOWLEDGEMENT
My parent/guardian and I have read and understand the athletic code. We understand that athletes must be enrolled in at least 5 classes (12 Running Start credits) or 6 middle school classes, attend all periods in a day to be eligible for practices and games AND athletes must pass all classes. Athletes shall not use or be at events where other students are using drugs, alcohol or tobacco. We understand that this code shall apply 24 hours a day, year around.
q
We accept the athletic code.
q
We do NOT accept the athletic code.
(Failure to accept the conditions of the athletic code will result in immediate ineligibility.)
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I certify that my responses above are valid and accurate and I understand the terms of the athletic code. I also pledge to represent my school and team with great sportsmanship behavior.
Student Athlete Signature Date Parent/Guardian Signature Date
Side 2 of 2
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