Athletic Participation Form - De Pere High School

A Physical Exam is required if student has not had an exam sinceApril 1, 2011.

Students should check on their physical exam date in the High School office.

This form must be completed and returned to the high school officeprior to participation in WIAA sports.

Athlete’s name (last, first, M.I.) ______Grade in 2012-13 ___ Age ___ Sex ____

Address ______City ______Zip Code ______

Home phone ______Work phone ______Birth date ______Height ____ Weight _____

Cell phone ______Email ______

Athlete:
  1. I have received and read the De Pere High School Co-Curricular Code of Conduct and I agree to abide by its principles.
  2. I have read and understand the Notice and Consent Statement which is printed on the reverse side of this form.
  3. I have read and understand the De Pere High School Parent-Athlete Handbook.
  4. I have read and understand the Athlete Concussion and Head Injury Information.
  5. I have read, understand and agree to abide by the WIAA High School Athletic Eligibility Information Bulletin which is printed in the Parent-Athlete Handbook. I further certify that if I have not understood any information contained in this WIAA Bulletin, I have sought and received an explanation of the information prior to signing this statement.
Athlete’s Planned Record of Participation for 2012-13. Please check allsports you are considering for participation.
GIRLS:Fall sports ___ Cross country; ____ Volleyball; ____ Golf; ____ Tennis; ____ Cheer; ______Swimming
Winter sports ____ Basketball; _____ Dance; ______Hockey
Spring sports ____ Track; ______Soccer; ______Softball
BOYS: Fall sports ___ Cross country; ____ Football; ____ Soccer
Winter sports ___ Basketball; _____ Wrestling; _____ Hockey
Spring sports ____ Track; ______Baseball; ______Golf; _____ Tennis
*Athlete’s signature ______Date ______
Parent/Guardian:
  1. I have received and read the De Pere High School Co-Curricular Code of Conduct and I agree to assist in the enforcement of its principles.
  2. I have read the Notice and Consent Statement which is printed on the reverse side of this form; I am aware of the risks involved in extra-curricular participation, and give my consent for my son/daughter to participate in extra-curricular activities sponsored by the school.
  3. I have read and understand the De Pere High School Parent-Athlete Handbook.
  4. I have read and understand the Parent Concussion and Head Injury Information, and agree that my child must be removed from practice/play if a concussion is suspected.
  5. I have read, understand and agree to abide by the WIAA High School Athletic Eligibility Information Bulletin (contained in the De Pere High School Parent-Athlete Handbook. I further certify that if I have not understood any information contained in this WIAA Bulletin, I have sought and received an explanation of the information prior to signing this statement.
  6. I will assume all responsibility for equipment issued to my son/daughter, which shall be returned after the completion of the sports season, or I will reimburse the school for replacement costs.
  7. I(we), the undersigned, feel that I(we) have adequate insurance protection for my(our) son/daughter while practicing or participating in interscholastic sports. I understand that I may purchase, at my own cost, adequate insurance from THE FIRST AGENCY, INC., but choose not to. (Brochures from THE FIRST AGENCY, INC., are available at the high school.)
  8. I fully realize that the school does not provide any insurance coverage.
  9. I give my permission for the Aurora BayCare Medical Center physicians, therapists and athletic trainers to discuss the medical condition of my son/daughter with the coaches and/or administrators at De Pere High School.
*Parent/Guardian’s signature ______Date ______
See Reverse Side
PHYSICAL EXAM
Complete this section if student has not had a physical exam
since April 1, 2011.
I find the above named physically fit to participate in athletics.
Restrictions (as to sports or length of time, if any) ______
______
Date of Examination ______
Name/Title of Examiner ______
Address of Examiner ______
______
Phone ______Fax ______
Examiner’s signature ______Date ______
Note to Parent/Athlete:The examiner may complete the WIAA Athletic Permit Card instead of this section. In that case, please attach the signed WIAA Athletic Permit card.
STATEMENT OF INSURANCE
Name of Parent/Guardian ______
Insurance Provider ______
Policy Number ______
NOTICE AND CONSENT STATEMENT
(Both the student and parent/guardian must read carefully.)
We understand that participation in school sponsored extra-curricular activities is a privilege and that all such participation is voluntary. We are aware that playing or practicing to play/participate in any extra-curricular activity can be dangerous, involving many RISKS OF INJURY. We understand that some risk is assumed by the participant as a matter of participating.
Because of the dangers of participating in such activities, I/we recognize the importance of following the instructions regarding playing techniques, training and other rules, etc. agree to obey such instructions.