Colorado Springs School District 11 Athletic Participation Form

COLORADO SPRINGS SCHOOL D-11 PARTICIPATION FORM

BOTH SIDES OF THIS FORM MUST BE COMPLETED Expires: ________________

(NOTE: Submit ONE Yellow Participation Form per year / Need NEW emergency card for EACH SPORT)

(FOR HIGH SCHOOLS ONLY)

PERSONAL INFORMATION SPORT(S): ________________________________ ________________________________

(HIGH SCHOOL USE ONLY)

School Yr: __________ ________________________________ ________________________________

__________________________________________________________________ __________________________ ___________

Last name (PLEASE PRINT) First Name Student ID Grade

_______________________________________________________________________________________________________________________

Address City State Zip

__________________________________ M____ F _____ ______________________ _______________________________________________

Birth Date Year started 9

grade School attended last semester

(ONLY FOR HIGH SCHOOL)

____________________________________________________________ ___________________________________ _________________________________

Parent or Guardian’s Name (PLEASE PRINT) Home # Work #

_________________________________________________________________________________________________ _________________________________

Parent Email Address Parent Cell #

PHYSICIAN INFORMATION (Signature Required)

COLORADO HIGH SCHOOL ACTIVITIES ASSOCIATION Initial Physical examination

Statement by Physician for Athletic Participation Medical Re-evaluation

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Date (valid for 365 days unless rescinded.) (PRINT) Physician Name Physician SIGNATURE

INSURANCE RELEASE (Signature Required - line #1 or #2)

COLORADO SPRINGS SCHOOL DISTRICT 11 ATHLETIC / ACTIVITY INSURANCE WAIVER

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 11does 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.

1) I feel that my present insurance coverage is adequate: _______________________________________________ ______________________

Parent or Guardian Signature Date

***** OR *****

2) I am purchasing student accident insurance for my son/daughter through the authorized agent approved by the Board of Education of Colorado

Springs School District 11: _________________________________________________________________ ______________________

Parent or Guardian Signature Date

PHOTO RELEASE (Signature Required – if permission ok)

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, as well as through other school related publications and events.

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.

_____________________________________________________________________________ _______________________________________

Parent or Guardian Signature Date

FEE SCALE & REQUIREMENTS

*** The full fee will be collected until proof of free or reduced lunch is submitted. ***

***The parent/guardian is responsible to provide proof of the student’s qualification for “Free” or “Reduced” lunch program. 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. Call 520-2924 if you need a copy of your letter. A current letter must be submitted each school year.

Please Note: The business office does not have access to this confidential information.

STATEMENT OF ELIGIBILITY & ASSUMED RISK GUIDELINES ((Signatures Required)

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 interschool 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 physical, physician’s

assistant, nurse practitioner or a certified/registered chiropractor, is physical 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: HTTP://WWW.D11.ORG/ATHLETICS and CHSAA guidelines for eligibility

found in “THE CHSAA COMPETITORS BROCHURE” found on the CHSAA website.

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 employees, arising out of such medical treatment.

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

IN THE WARNING ABOVE; ELIGIBILITY GUIDELINES; INSURANCE OR PHOTO RELEASE AND

PAYMENT AGREEMENT SHOULD NOT SIGN THIS PERMISSION FORM.

_______________________ _______________________________________________________

Date Parent or Guardian Signature

____________________________ _____________________________________________________________________

Date Student Signature

OFFICE USE ONLY – (For High School Use Only)

F/L Letter? _______

Obligation CK

____________

Fall Sports Fee

$______________

Sport

_______________________________________

Type Payment

________________

Date

_______________________

Obligation CK

____________

Winter Sports Fee

$______________

Sport

_______________________________________

Type Payment

________________

Date

_______________________

Obligation CK

____________

Spring Sports Fee

$______________

Sport

_______________________________________

Type Payment

________________

Date

_______________________

BOTH SIDES OF THIS FORM MUST BE COMPLETED