Form 12 - Athletic Participation Required Forms
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reQuired for Student athleteS | form
Athletic PArticiPAtion required Forms
STUDENT INFORMATION
Student name:
age:
grade:
date of Birth (mm/dd/yyyy):
addreSS:
City:
Zip:
home phone:
Cell phone:
email:
PARENT / GUARDIAN INFORMATION
parent / guardian name:
employer:
home phone:
Cell phone:
email:
parent / guardian name:
employer:
home phone:
Cell phone:
email:
In an emergency, when parents (or legal guardians) cannot be notified, please contact:
name:
relationShip:
Cell phone:
ACADEMIC REQUIREMENTS
dubuque community school district will follow the ihsAA/iGhsAu guidelines for academic eligibility. the iowa department of education
guidelines requires students to pass All subjects at the end of each grading period (semester grades). if a student has failed one or more
subjects, a period of ineligibility will be assessed. middle school students will follow district Policy 5305 academic eligibility.
DOCTOR’S PERMIT - PHYSICAL ExAMINATION
every student participating in ihsAA and/or iGhsAu athletics, must have a valid physical on file with their school’s Activities office.
Physicals are valid for one year (365 days) from the date of examination.
family phySiCian:
phone:
preferred hoSpital:
phone:
family dentiSt:
phone:
glasses [ ]
[ ]
contacts [ ]
[ ]
dentures [ ]
[ ]
do you wear:
yeS
no
yeS
no
yeS
no
date of laSt tetanuS BooSter:
liSt any known allergieS, drug reaCtionS, or other pertinent mediCal information:
CONSENT FOR MEDICAL TREATMENT
iowa law requires a parent's, or legal guardian's, written consent before their son or daughter can receive emergency treatment, unless, in
the opinion of a physician, the treatment is necessary to prevent death or serious injury.
As the parent(s), or legal guardian(s), of the child named on this form, i (we) authorize emergency medical treatment or hospitalization that
is necessary in the event of an accident or illness of my (our) child. i (we) understand that this written consent is given in advance of any
specific diagnosis or hospital care. this written authorization is granted only after a reasonable effort has been made to contact me (us).
__________________________________________
________________
PArent / GuArdiAn siGnAture
dAte
DCSD SCHOOL BOARD POLICY #5305 PARTICIPATION CODE FOR ACTIVITIES
By affixing my signature to this form, i affirm that i have read the Participation code for Activities. i understand all the rules governing
participation in the dubuque community school district activities programs and i agree to abide by those rules.
__________________________________________
__________________________________________
student siGnAture
PArent / GuArdiAn siGnAture
note: if you wish to save data typed into this form, first save the file on your computer and re-open from your computer prior to typing.
05/2014
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