Form Ins. S.4-6/1 - Pre-Participation Physical Evaluation Form Page 2
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1
2Athlete’s Section
List sports you plan to participate in this school year: ________________________________________________________
___________________________________________________________________________________________________
This application to participate in interscholastic athletics is entirely voluntary on my part and is made with the understanding
that I have not to the best of my knowledge violated any of the eligibility rules and regulations of the Nebraska School
Activities Association (NSAA). I will adhere to the rules and regulations set forth by the Bellevue Public School District,
coaching staff, and the NSAA. I recognize that it is a privilege to participate in athletics and will strive to earn respect for
myself, school, and community. I fully understand that the school has policies that apply to athletic/activity programs listed in
the Parent-Student and the Athletic Handbooks. Also, I hereby state that, to the best of my knowledge, the answers to the
Pre-participation Physical Evaluation History Form are complete and correct.
_________________________________________________
Athlete’s Name (Please Print)
_________________________________________________
_______________________
Athlete’s Signature
Date
Parent/Guardian(s) Section
The undersigned parent/guardian:
1.
gives consent for the above named athlete to participate in school sponsored interscholastic athletics and activities,
except those determined to be inappropriate on the basis of a physical examination, realizing that such activity has
the potential for injury which can occur in all sports. I / We understand that even with the best coaching, the correct
protective equipment and abiding by the rules of the sport, injuries are still a possibility.
2.
gives consent for the above named athlete to travel with any school team, of which he/she is a member, to any local
or out of town events/competitions.
3.
gives consent for the coach or school representative to obtain any emergency medical care (Permission to Treat)
that may be needed for the athlete during travel or an athletic event/competition.
4.
verifies that the athlete is adequately insured against injury that might be incurred during athletic participation.
5.
hereby give permission for the release of the athlete’s medical history and the results of their physical examination
to the school for purposes of participation in athletics and activities.
6.
dose hereby release, hold harmless, and indemnify the Bellevue Public School District and supervisors from any
liability for injuries and/or property damage incurred by the above named student athlete while participating in
interscholastic athletics and activities.
7.
fully understands that the athlete is required to abide by the rules and regulations set forth by the Bellevue Public
School District, coaching staff, and the Nebraska School Activities Association. I / We recognize that it is a privilege
to participate in athletics.
_________________________________________________
Parent/Guardian Name (Please Print)
_________________________________________________
_______________________
Parent’s/Legal Guardian’s Signature
Date
Notary Section (Required for High School Students Only)
STATE OF NEBRASKA
)
) ss.
COUNTY OF SARPY
)
SUBSCRIBED AND SWORN to before me, a notary public, on this _____ day of
_______________________, 20___.
____________________________________
Notary Public
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