High School Athletic Clearance Form

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Office Use Only
 ASB
 Concussion/ Sudden Cardiac Arrest
 Fines ($_____)
 GPA (_______)
 Passing 5
 User Fee
 Student Emergency Form
 Physical (Exp. Date:
)
KENNEWICK SCHOOL DISTRICT HIGH SCHOOL ATHLETIC CLEARANCE
Male:  Female: 
Student Name:
Student Grade: ______
Student ID Number:
Student Birth Date:
Student Address:
City:
Zip:
Parent Email Address:
Name of adult person(s) with whom student resides:
Father:
Mother:
Court Appointed Guardian:
Other:
Relationship:
Phone (Work): __________________ (Home): _______________________
(Cell): ____________________
 Baseball
 Basketball
 Bowling
 Cross Country
Current Activity:
 Football
 Golf
 Gymnastics  Soccer
 Softball
 Swim
 Tennis
 Track
 Volleyball
 Wrestling
 Cheer
 Dance
 Kamiakin
 Kennewick  Southridge
Which school boundary do you reside in:
 No
 Yes
th
Since 7
grade, have you repeated a grade or failed to complete any semester of school?
 NA
 No
 Yes
Have you repeated a grade or failed to complete any semester in high school?
Foreign Exchange Student?  No
 Yes
What calendar year did you enter high school? 20_____
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; Summer Camp Athlete / 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; Training Rules for Summer 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 HIGH SCHOOL USE ONLY Feb 2016)

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