Alternate Year Athletic Permit Form printable pdf download

DE SOTO AREA SCHOOL DISTRICT

DE SOTO HIGH SCHOOL

ATHLETIC PARTICIPATION FORM

20____ - ________

Student’s Name:______________________________________________ Grade: ___________ Birth date: _____/_____/_____

Last

First

Middle Initial

Present Address: ____________________________________________________________ Telephone: ___________________

Sport: Fall: __________________________Winter: ____________________________ Spring: ___________________________

Each of the following sections must be completed before the above named athlete will be allowed to practice.

SECTION I: W.I.A.A. ALTERNATE YEAR ATHLETIC PERMIT

WISCONSIN INTERSCHOLASTIC ATHLETIC ASSOCIATION

ALTERNATE YEAR ATHLETIC PERMIT

Physical Date: ________________________________________

Name: __________________________________________________ Grade: _______ Date of Birth:__________________

Last

First

Middle Initial

Parent’s Place of Employment: ________________________________________________________________________________

Family Physician: ______________________________________________ Family Dentist: _______________________________

Name of Private Insurance Carrier: _____________________________________________________________________________

Policy Numbers and Address: _________________________________________________________________________________

1. I hereby give my permission for the above named student to practice, compete, and represent the school in WIAA

approved sports.

2. I also attest to the fact that the above named student has had no injury or illness serious enough to warrant a medical

evaluation prior to participating this school year.

3. I further grant permission for any medical records pertaining to the health of the above named student be made available

as necessary to the proper school district personnel and appropriate health care providers, including emergency medical

personnel.

4. It is recommended that information regarding your child’s allergies and prescribed medication be made available.

PARENT: If there is any question that this student may not be qualified for athletic competition without, at least, a partial

re-evaluation, contact your medical advisor before signing card.

x________________________________________________________________ DATE: __________________________________

(Signature of Parent/Guardian)

ALL STUDENTS PARTICIPATING IN INTERSCHOLASTIC ATHLETICS MUST HAVE THIS ALTERNATE YEAR

CARDON FILE AT THEIR SCHOOL PRIOR TO PRACTICE OF PARTICIPATION.

Alternate Year Athletic Permit Form