Participation Packet

Student Athlete Name *

First

Last

Gender *

Male Female

Student Athlete Birthdate (example 01/01/1995) *

Student Athlete age as of June 15, 2013 *

2013-2014 Grade Level *

9 10 11 12

School of Attendance in 2013-2014 School Year *

School Year You Started 9th Grade *

2010-2011 2011-2012 2012-2013 2013-2014

Name of Schoool You Started 9th Grade *

Parent/Guardian/Caregiver Name (person student-athlete legally resides with) *

First

Last

Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Telephone Number *

Parent/Guardian Email *

Signature of Parent or Guardian *

Date (example 01/01/1995) *

Name of Medical Insurance Company *

Policy/Certificate Number (required) *

Optional Student Accident Insurance (Check the appropriate boxes) *

Sports Only Coverage (excludes tackle football) Tackle Football Coverage (football only I have private insurance and decline optional Student Accident Insurance.

Parent/Guardian Name *

First

Last

Date (example 01/01/1995) *

Parent's Residence Statement (Residential/Transfer Eligibility) *

We presently live within the boundaries of Clairemont High School's residential attendance area We presently DO NOT live within the boundaries of Clairemont High School's residential attendance area. In the space provided below identify the attendance program, VEEP, Choice, or Special Education, etc. you are utilizing to attend Clairemont High School and the high school of your residential attendance area below. My student has been continuously enrolled at Clairmont High School since initially entering 9th grade My Student has NOT been continuously enrolled at Clairemont High School since entering 9th grade The use of undue influence by any person or persons to secure or retain a student or to secure or retain one or both parents/guardians of a student as residents may cause the student to be ineligible for high school athletics for a period of one year and shall jeopardize the standing of the high school in CIF. WE CERTIFY THAT THERE HAS BEEN NO UNDUE INFLUENCE IN OUR DECISION TO ATTEND CLAIREMONT My Student has been legally living with the same parent(s)/guardian(s) since entering 9th grade My student is living with somebody different than when they entered the 9th grade. (if yes, please contract the site Athletic Director)

If not living within school site's residential attendance area, please name special attendance program *

If student has not been continuously enrolled at Clairemont High School since entering 9th grade, please list all high schools attended, all sports and levels participated in at previous school, reason for leaving former school, whetehr your last school was a charter, alternative or anything other than a comprehensive high school. *

Signature of Parent/Guardian *

Date (example 01/01/1995) *

Fathers Name *

First

Last

Father's Work Telephone *

Father's Cellular Telephone *

Mother's Name *

First

Last

Mother's Work Telephone *

Mother's Cellular Telephone *

Family Doctor's Name *

First

Last

Family Doctor's Telephone *

Emergency Contact Name *

First

Last

Emergency Contact Relationship (example: Friend, Brother, etc.) *

Emergency Contact Telephone *

1. Has had injuries requiring medical attention *

Yes No

2. Has had an illness requiring hospitalization *

Yes No

3. Is under physician's care at this time *

Yes No

4. Has had coughing, wheezing, or trouble breathing during or after activity *

Yes No

Has had asthma *

Yes No

Has had seasonal allergies that require medical treatment *

Yes No

5. Are you currently taking any prescription or non-prescription (over the counter) medications or pills using an inhaler? *

Yes No

Have you ever taken any supplments or vitamins to help you gain or lose weight or improve your performance? *

Yes No

6. Have you ever passed out during or after exercise? *

Yes No

Have you ever been dizzy during or after exercise? *

Yes No

Have you ever had chest pain during or after exercise? *

Yes No

Do you get more tired quickly than your friends do during exercise? *

Yes No

Have you ever had racing of your heart or skipped heartbeats? *

Yes No

Have you ever been told you have a heart murmur? *

Yes No

Has any family member or relative died of heart problems or of sudden death before age 55? *

Yes No

Have you had a severe viral infection (for example, myocarditis, or mononucleosis) within the last month? *

Yes No

Has a physician ever denied or restricted your participation in sports for any heart problems? *

Yes No

7. Have you ever had a head injury or concussion? *

Yes No

Have you ever been knocked out, become unconscious, or lost your memory? *

Yes No

Have you ever had a seizure? *

Yes No

Do you have frequent or severe headaches? *

Yes No

Have you ever had numbess or tingling in your arms, hands, legs, or feet? *

Yes No

Have you ever had a stinger, burner, or pinched nerve? *

Yes No

8. Have you ever become ill or felt light headed from exercising in the heat? *

Yes No

9. Is hearing impaired, has glasses/contact lenses. *

Yes No

10. Has fixed or removable appliances in mouth. *

Yes No

11. Is there a reason for this individual to avoid participation on a certain sport? *

Yes No

Please explain if yes response: *

12. Date of last TETANUS immunization *

Date of last MEASLES immunization *

Date of last Hepatitis B immunization *

Date of last Chickenpox immunization *

I Have Read and Agree With the Terms & Conditions Below *

Yes

Parent/Guardian Signature *

Athletic Participation Packet Due Dates

Athletic Participation Packet