______, ______
Student’s Last Name Student’s First Name
Revised 8-1-11
Robeson County High Schools
STUDENT-ATHLETE ELIGIBILITY and PERMISSION FORM
This form must be completed and filed in the office of the Athletic Director before the student/athlete will be allowed to participate in any athletic activity.
(Please Print All Information)
School:______Grade: _____ Student ID Number: ______Date:______
ACTIVITY: ______
STUDENT/ATHLETE NAME: ______, ______, ______
Last First Middle
Student/Athlete Date of Birth: ______
Month Day Year
Address: ______Phone:______, ______, ______
Street Home Work Cell
______
City State Zip Code
Parent/Legal Custodian: ______, ______
Last First Middle
Address: ______Phone:______, ______, ______
Street Home Work Cell
______
City State Zip Code
We (Student/Athlete & Parent/Legal Custodian), certify that the above information is accurate and that the home address on all forms/records is the sole bonafide residence of the student/athlete and that we will notify the school/principal immediately of any changes in residence, since such a move may alter the eligibility of the student/athlete. Falsification of residence information will result in loss of eligibility for 365 days. Unless, there is an approved out of district transfer form on file at the Central Office.
Signature of Student/Athlete: ______Date: ______
Signature of Parent/Legal Custodian: ______Date: ______
ELIGIBILITY
· AGE (cannot become 19 years of age before August 31 of current school year)
· ATTENDANCE (in attendance at least 85% of the previous semester – absent no more than 13.5 days
· ACADEMICS - High School (must pass Block Schedule – 3 out of 4)
Middle School (the student must pass at least one less course than the number of required
core courses each semester and meet promotion standards established by the LEA.
· EIGHT SEMESTER RULE (cannot participate for a period lasting longer than 8 consecutive semesters beginning with first entry in the 9th grade or on High School team)
· MAXIMUM NUMBER OF SEASONS (Four separate seasons – 1 per year)
· PASS PHYSICAL EXAM (a physical must be done for each school year)
If you are interested in free or low cost health insurance for your child, call (910) 671-3200 or visit the website: http://www.nchealthystart.org/public/childhealth/index.htm.
PHOTOGRAPHIC/VIDEOTAPING PERMISSIONThis Section Allows You As A Parent Or Guardian To Choose Whether Your Child May Be In A Video, Photograph, Or Other Illustration Used By The Public Schools of Robeson County System Or The News Media.Robeson County Schools Uses Photographs, Slides, Videos, Or Illustrations Of Students For Many Purposes Such Photographs, Videos, Or Other Illustrating Material Which May Be Used In Newsletters Or Publications Produced By The School System, In Slide Presentations And/Or Videos About The Schools, By The News Media In School-Related News Coverage, In Video Productions Aired On Television Produced By The School System Or In Other Similar Forms Of Communication.
CHECK ONE:
_____ We Give Our Permission To The Public Schools of Robeson County or The News Media To Make Photographs, Slides, Videos, or Illustrations of our Child. Further, We Authorize Their Use Without Inspecting or Approving The Finished Product or Its Specific Use.
_____ We Do Not Give Our Permission For Our Child To Be Included In Presentations by the Public Schools of Robeson County System or The News Media.
Signature of Parent/Legal Custodian: ______Date: ______
Parental Permission
(To be completed by the parent or guardian)
PARENT/LEGAL CUSTODIAN RELEASE OF LIABILITY and PERMSSION FORM
WE, THE UNDERSIGNED PARENT/LEGAL CUSTODIAN, DO HEREBY AGREE AND CONSENT FOR THE ABOVE STUDENT/ATHLETE TO PARTICIPATE IN INTERSCHOLASTIC SPORTS. WE DO FURTHER RELEASE AND WAIVE, AND AGREE TO INDEMNIFY, HOLD HARMLESS THE ROBESON COUNTY BOARD OF EDUCATION, THE INDIVIDUAL MEMBERS, AGENTS, EMPLOYEES AND REPRESENTATIVES THEREOF, AS WELL AS THE PROGRAM’S SUPERVISORS, FROM AND AGAINST ANY CLAIM WHICH WE MAY HAVE OR CLAIM TO HAVE, KNOWN OR UNKNOWN, DIRECTLY OR INDIRECTLY, FOR PARTICIPATION IN ANY APPROVED EXTRA-CURRICULAR OR CO-CURRICULAR ACTIVITY OR THE RENDERING OF EMERGENCY MEDICAL PROCEDURES OR TREATMENT, IF ANY.
We also understand that participation in extra and/or co-curricular activities may involve an element of danger and risk of personal injury, and we have read the above release of liability, and have opted to allow the above athlete to participate with that awareness in mind.
Signature of Parent/Legal Custodian: ______Date: ______
Signature of Student/Athlete (18 or older): ______Date: ______
In accordance with the rules of the NCHSAA, I hereby give my consent for the participation of my student athlete named below for the following activities circled below:
Baseball Football Softball
Basketball Golf Swimming
Bowling Indoor Track Tennis
Cheerleading Outdoor Track Volleyball
Cross Country Soccer Wrestling
Others (School may list): ______
Date: ______Parent/Guardian’s Signature ______
Name of Student Athlete: (Please Print) ______
Name of Parent/Guardian: (Please Print) ______
Address of Parent/Guardian: ______
NOTE: This statement is valid for one school year only.
Emergency authorization: In the event I cannot be reached in an emergency, I hereby give permission to physicians selected by the coaches and staff to hospitalize, secure proper treatment for and to order injection and anesthesia surgery for the person named above.
Name of family Physician: ______
Parent Signature: ______
Date: ______
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