Middle School Athletic Clearance Form printable pdf download

Office Use Only

 ASB

 Concussion/ Sudden Cardiac Arrest

 Fines ($_____)

 GPA (_______)

 Passing 6 or 7

 User Fee

 Student Emergency Form

 Physical (Exp. Date: ____________)

KENNEWICK SCHOOL DISTRICT MIDDLE SCHOOL ATHLETIC CLEARANCE

Male:  Female: 

Student Name: ___________________________________________

Student Grade:

Student ID Number:

Student Birth Date:

Student Address: _________________________________________

City: ____________________ Zip:

Name of adult person(s) with whom student resides:



Father: _______________________________________________________________________________



Mother: _______________________________________________________________________________



Court Appointed Guardian: ________________________________________________________________



Other: _________________________________________ Relationship: ___________________________

Phone (Work): __________________ (Home): _______________________

(Cell): ____________________

Current Activity:

FALL

WINTER I

WINTER II

SPRING

 Soccer

 Boys Basketball

 Girls Basketball

 Softball

 Football

 Dance

 Wresting

 Baseball

 Cross Country

 Track

 Volleyball

Which school boundary do you reside in:  Chinook  Desert Hills  Highlands  Horse Heaven  Park

 No

 Yes

Return Physical Form?

 No

 Yes

Return Emergency Form?

STUDENT/PARENT VERIFICATION OF RECEIPT & VERIFICATION OF UNDERSTANDING

By initialing and signing below you verify that you have read and understand all documents (available upon request or at

) listed below. Further, by initialing and signing below you verify that you will abide by all policies,

procedures, protocols, etc. listed therein.



Sport Specific Safety Guidelines: I understand the rules and procedures and the necessity of using proper

techniques while participating in _____________________________ (Current Activity).

Parent /Guardian Initials: _________

Student Initials: _________



Extracurricular Athletic / Activity Information; Student Expectations/ Anti Hazing: I understand and agree to all

stated conditions of participation in extracurricular activities in the Kennewick School District.

Parent /Guardian Initials: _________

Student Initials: _________



Training Rules for Interscholastic Activity Participation: I understand that my conduct and training habits must be

appropriate in order to ensure my continued participation in interscholastic activities. I understand and agree to abide

by the training rules for interscholastic activity participation.

Parent /Guardian Initials: _________

Student Initials: _________



Concussion and Sudden Cardiac Arrest Awareness: I have read and understand the sudden cardiac arrest

information sheet and concussion guidelines. Concussions can range from mild to severe and can disrupt the way the

brain normally works. Even though most concussions are mild, all concussions are potentially serious and may result

in complications including prolonged brain damage and death if not recognized and managed properly. If my child

reports any symptoms of concussion, or if I notice the symptoms or signs of concussion, I will seek medical attention

right away.

Parent /Guardian Initials: _________

Student Initials: _________

Parent Signature: _____________________________ Student Signature: ___________________________________

Date: ______________________________________

Date: ______________________________________________

(KSD MIDDLE SCHOOL USE ONLY Feb 2016)

Middle School Athletic Clearance Form

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