Colorado Springs School District Athletic Participation Form

SPORT(S):

______________________

______________________

______________________

_______________________ Physical Expires: ___________________

COLORADO SPRINGS SCHOOL DISTRICT #11 PARTICIPATION FORM

Last name

First Name

Student ID

School attended last semester

M____ F _____

Grade______

___________________________________________

_____________________________________

______________ ________________________

Address

City

State

Zip

Birth Date

_____________________________________________________________

______________________

_______ ______________

___________________________

Parent or Guardian’s Name

Parent Email Address

Home #

Work #

Cell #

________________________________________

_____________________________________

___________________ ___________________ ___________________

Physician

Hospital Preference

Emergency Contact Name & Phone#

Health Concerns:

_____________________

______________________ __________________________________________

__________________________________________________

COLORADO HIGH SCHOOL ACTIVITIES ASSOCIATION

STATEMENT BY PHYSICIAN FOR ATHLETIC PARTICIPATION

I hereby certify that I have examined the above named student and that this student was found physically fit to engage in the following sports: baseball,

basketball, cheer, cross county, football, golf, gymnastics, softball, tennis, swimming, track and field, wrestling, volleyball, soccer, ice hockey, and lacrosse.

(Please cross out any sport in which the student should not participate.)

____________________________________________________________________________________________________________________________________________

Date of exam (valid for 365 days unless rescinded)

(PRINT) Physician Name and Phone Number

SIGNATURE

COLORADO SPRINGS SCHOOL DISTRICT 11 ATHLETIC ACTIVITY INSURANCE WAIVER /PHOTO RELEASE / STATEMENT OF ELIGIBILITY & ASSUMED RISK:

This statement releases Colorado Springs School District 11 schools of responsibility in case of accident to my son/daughter while he/she is participating in interscholastic

activities. I fully understand that Colorado Springs School District 11 does not provide accident and health insurance coverage for my son/daughter while he/she is

Participating in interscholastic activities. However, such insurance is made available by the Colorado Springs School District 11 through an authorized agent. I further

understand that it is my responsibility to provide accident insurance for my son/daughter. I hereby give my permission to Colorado Springs School District 11 to publish

photographs and/or videos of my student. I understand that such publication may occur through school and/or district newsletters, media releases, public reports, training

material, assemblies, public meetings, the district websites, I further understand that this permission for the Colorado Springs School District 11 to publish will remain in force

until such a time as the District Communications Office or School Principal is notified by me in writing of its withdrawal. To purchase affordable accident insurance for your

student, please go to

and click the “Enroll Now” button.

WARNING: Although participation in supervised interscholastic athletics and activities may be one of the least hazardous which a student will engage in or out of school, by

its nature, participation in the interscholastic athletics includes a risk of injury which may range in severity from minor to long-lasting catastrophic. Although serious injuries

are not common in supervised school programs, it is impossible to eliminate this risk. Participants can and have the responsibility to help reduce the chance of injury. Players

must obey all rules, report all physical problems to their coaches, follow a proper conditioning program, and inspect their equipment daily. By signing this form, we

acknowledge that we have read and understand this warning. No student shall represent their school in interscholastic athletics until this statement is on file and signed by

his/her parent or legal guardian and a physical form certifying that he/she has passed an adequate physical examination within one year, noting that in the opinion of the

examining physician, physician’s assistant, nurse practitioner or a certified/registered chiropractor, is physically fit to participate in high school athletics; that student has the

consent of his/her parents or legal guardian to participate; and, the parents and participant have received a Concussion Fact Sheet and have read, understand and agree to

the “THE CSSD11 ATHLETIC HANDBOOK” found at:

and CHSAA guidelines for eligibility found in “THE CHSAA COMPETITORS BROCHURE”

found on the CHSAA website.

CONSENT FOR EMERGENCY TREATMENT: I hereby give my consent for the student mentioned on this form to compete in athletics for Colorado Springs School District 11, in

Colorado High School Activities Association approved sports except those crossed out below. Baseball, basketball, cheer, cross county, football, golf, gymnastics, softball,

tennis, swimming, track and field, wrestling, volleyball, soccer, ice hockey, and lacrosse. In consideration of my son’s/daughter’s opportunity to participate in interscholastic

activities, hereby consent to emergency treatment, hospitalization or other medical treatment as may be necessary for the welfare of the above named child, by a physician,

qualified nurse, and/or hospital, in the event of injury or illness during all periods of time in which the student is away from his/her legal residence as a member of an

interscholastic activity team or group, and hereby waive on behalf of myself and the above named child and liability of Colorado Springs School District 11, any of its agents or

.

PARENT OR GUARDIAN AND STUDENT WHO DO NOT WISH TO ACCEPT THE RISK DESCRIBED IN THE

employees, arising out of such medical treatment

WARNING ABOVE; ELIGIBILITY GUIDELINES; INSURANCE OR PHOTO RELEASE AND PAYMENT AGREEMENT SHOULD NOT SIGN THIS PERMISSION FORM.

______________ _________ ________________________________________________________________________________________

Date

Parent or Guardian Signature

520-2924

FEE SCALE REQUIRMENTS: PARENTS MUST PROVIDE PROOF OF FREE OR REDUCED LUNCH TO BE ELIGIBLE FOR FEE SCALE DISCOUNTS Call

to obtain your letter

The full fee will be collected until proof of free or reduced lunch is submitted. A copy of the current school years National School Lunch Program approval letter from CSSD11

Food Service must be brought to the business office at the same time of the sports registration.. A current letter must be submitted each school year. Please Note: The

business office does not have access to this confidential information.

FALL F/R letter? ____ Oblg?____ $ amt paid ______

WINTER F/R letter? ____ Oblg?____ $ amt paid ____

:

SPRING

F/R letter? ___ Oblg?___ $ amt paid ____

Sport:

Pmt Type

Date

Sport:

Pmt Type

Date

Sport:

Pmt Type

Date

___________ __________ ___________

___________ __________ ___________

___________ _________ ___________