Wake County High School Athletic Participation Form
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4Wake County High School Athletic Participation Form
Name: _____________________________ Home Phone: __________________ Circle Grade 9 10 11 12
Student ID # _____________________________ School Attended Last Year ___________________________
Gender: M
F
Date of Birth: ________________________
Race: __________
Age: ______
Father’ s Name: ________________________ Daytime Phone, Pager, Cell Phone: _____________________
Mother’ s Name: _______________________ Daytime Phone, Pager, Cell Phone: _____________________
*Legal Custodian: _______________________ Daytime Phone, Pager, Cell Phone: _____________________
*Please note the residency requirements and definition of legal custodian on page 4 of this document.
Street Address: _________________________________________
County: _______________________
City: _________________________________State: _________________Zip Code: _____________________
Alternate Emergency Contact Person:_____________________________Daytime Phone:_________________
Attach necessary documentation for Medical Alerts such as allergic reactions, contacts, etc.
Convictions: Check the box that applies to, ____________________________________________(student name):
Is not convicted of a felony in this or any other state OR adjudicated as a delinquent for an offense that would be a
felony if committed by an adult in this or any other state
Is convicted of a felony in this or any other state
Is adjudicated as a delinquent for an offense that would be a felony if committed by an adult in this or any other state
The following must be completed if the student is convicted of a felony or is adjudicated as a delinquent:
Convicted or adjudicated of: ______________________________________________________________________
City and State: ___________________________________
Date Convicted/Adjudicated: __________________
Description of Offense:
_________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Court Counselor: ___________________________________Telephone Number: ___________________________
Request for Permission: We, the undersigned student and the student’ s parent/legal custodian, apply for permission to
participate in interscholastic athletics in the following sports: (Please check all sports that apply)
( ) Basketball
( ) Football
( ) Soccer
( ) Track
( ) Lacrosse
( ) Baseball
( ) Golf
( ) Softball
( ) Volleyball
( ) ________________
( ) Cheerleading
( ) Gymnastics
( ) Swimming
( ) Wrestling
( ) ________________
( ) Cross Country
( ) Indoor Track
( ) Tennis
*Weight lifting may be required component of
conditioning for any sport.
Insurance: The Wake County Public School System (WCPSS) furnishes an Interscholastic Athletic Insurance Policy that
provides limited benefits for all students in the system who participate in high school sponsored and supervised interscholastic
athletic activities. The policy provides excess coverage for students with other insurance coverage, but it pays only when other
benefits have been exhausted. In cases in which a student has no other coverage with either a commercial insurance agency,
Medicare, or Medicaid, the WCPSS athletic insurance policy is the primary policy.
If your son or daughter should be injured while participating in a high school sponsored or supervised interscholastic athletic
event, the following procedures must be followed to process a claim under the insurance provided by WCPSS:
Pick up a claim form at your school.
See a physician within 30 days of the injury.
Complete and submit the Accident Claim form. The claim form must be filed with the insurance company within 60
days of the injury and should include the Explanation of Benefits form from your primary insurance carrier. Please list
below the name of your primary insurance carrier and policy number.
Name of Insurance Company
Policy Number
Form 2305
March 2006
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