Sports Participation Certificate And Evaluation
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3Sports Participation Certificate & Evaluation
First Name
Middle Initial
Last Name
Social Security Number
Date of Birth
Age
Sex
Grade
School Attending
qMale qFemale
/
/
Mailing Address, City, State and Zip Code
In case of emergency, contact:
Name
Phone number
Family Doctor
Family Doctor's phone number
q Baseball
q Soccer
q Basketball
q Softball
q Cheerleading
q Tennis
Check all
that apply
q Cross Country
q Track/Field
q Football
q Volleyball
q Golf
q Other_____________
This application to represent my school in interscholastic athletics is entirely voluntary on my part and is made with the
understanding that I have studied and understand the eligibility standards that I must meet to represent my school and
that I have not violated any of them. I understand that if I do not meet the citizenship standards set by the school or if I
am ejected from an interscholastic contest because of an unsportsmanlike act, it could result in me not being allowed to
participate in the next contest or suspension from the team either temportily or permanently. I have completed and/or
verified that part of this certificate which requires me to list all previous injuries or additional conditions that are known to
me which may affect my performance is so representing my school, and I verify that it is correct and complete.
Student’s signature __________________________________________________________
Date: _____/____/_____
Parent Permission and Authorization for Treatment
qYes
qNo
We hereby give our consent for our child to represent his/her school in interscholastic athletics. We
give our consent for him/her to accompany the team on trips and will not hold the school responsible
in case of accident/injury whether it be en route to or from another school or during practice or an
interscholastic contest. We agree to hold the school district of which this school is a part, its employees,
agents, representatives, coaches and volunteers harmless from any and all liability, actions, causes of
action, debts, claims or demands of every kind and nature whatsoever which may arise by or in connec-
tion with participation by my child in any activites related to the interscholastic program of the school.
qYes
qNo
If we cannot be reached and in the event of an emergency, we give our consent for the school to
obtain through a physician or hospital of its choice, such medical care as is reasonably necessary for
the welfare of the student, if injured in the course of school athletic activities.
qYes
qNo
We understand that the school may not provide transportation to all events, and permit my child to
drive his/her vehicle in such a case.
qYes
qNo
We further state that we have completed that part of this certificate which requires us to list all
previous injuries or additional conditions that are known to us which may affect this athlete’s
performance or treatment, we certify that it is correct and complete.
qYes
qNo
The MSHSAA bylaws provide that a student will not be permitted to practice or compete for a school
until it has verification that he/she has basic athletic insurance coverage. Our child is covered by:
Insurance Company_________________________________________________________________
Policy Number______________________________________________________________________
Parent / Guardian signature___________________________________________________Date: ______/______/______
(All parents or guardians must sign)
________________________________________________Date:______/______/______
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