2016 - 2017 Goupeville Middle and High School

Co-Gurricular/Athletic Participant EIigi bility STUDENTS WILL BE ALLOWED TO PARTICIPATE WHEN PAPERWORK IS COMPLETED And SIGNED

STUDENT INFORMATION STUDENT'S FIRST NAME

DOB

LAST NAME

FALL SPORT' AGTIVITY

AGE

GRADE

GENDER

SPRING SPORT/ACTIVITY

WINTER SPORT'ACTIVITY

HOME PHONE

HOIìIE ADDRESS/MAILING ADDRESS

PR¡MARY PARENT or GUARDIAN NAfllE and GELL#

SECONDARY PARENT,GUARDIAN NAME ANd CELL#

EMERGENCY INFORMATION Emergency Contact Name #l (Alternate

other than parenUguardían)

Gontact #

Emergency Contact Name #2 lAlternate

other than parenUguard¡an)

Contact #

EMERGENCY OBSERVATION and/or TREATMENT PERMSISSION or WAIVER lf the parents/guardian and/or authorized physician named above cannot be reached at the time of an emergency, and if immediate observation or treatment is urgent in the judgment of the school authorities, I authorize and direct the school authorities to send the student (properly accompanied) to the hospitalor Licensed Health Care Provider most easily accessible and for such doctor to render such observation and treatment as is immediately necessary PHYSICIAN PHONE PHYSICIAN

HOSPITAL PHONE

PREFERRED HOSPITAL

PLEASE NOTE: COACHES CARRY THIS INFORMATION AT ALL TlftllEs. PLEASE INCLUDE ALL HEALTH CONDITIONS INGLUDING A CONCUSSION THAT MAY BE PERTINENT TO YOURATHLETE. PLEASE CHECK ALL THAT APPLY: _severe bee _reaction allergies _reduced hearing

sting

_asthma _seizure disorder _heart problems _vision problems _diabetes other (please list) _food allergies: Will medication be taken at

school?

lf yes, a "Parent Authdization to Adm¡n¡ster Med¡cation" form must be on file in the Heallh Roofi

b€fæ

YES-

NO

med¡cetion rnay b€ dispensed in lhe ofllce at schoou

YES During the last year, has your child been seriously ill? Had surgery, serious injury, and/or a CONCUSSION? *rryespleasenoredare(s)anddera¡rsberow YES

NO NO

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MEDICAL INSURANCE VERIFICATION

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-

PLEASE CHOOSE ONE BELOW: STUDENTS MUST HAVE HEALTH INSURANCE INFORII'IATION ON FILE IN ORDERTO PARTICIPATE

Please make sure all areas are accurate and complete.

2016 - 2017 Coupeville Middle and High School

Co-Gurricular/Athletic Participant Eligibility STUDENTS WILL BE ALLOWED TO PARTICIPATE WHEN PAPERWORK IS COMPLETED ANd SIGNED

RELEASE FOR TRANSPORTATION OF STUDENTS FROM OFF CAMPUS ATHLETIGS/ACTIVITIES

ALL students will be returning to the Coupeville Middle/High Schoolfrom away athletic/activity events ON the school transportation. Aiternate locations to pick up your child other than the school are noted below. Please choose a location: (PLEASE NOTE: NO OTHER DROP OFF LOCAT¡ONS ARE AUTHORIZED) I authorize my child to be dropped off on the return to school at the: tr GREENBANK STORE (if returning via the Clinton/Mukilteo Ferry) tr BIBLE BAPTIST GHURCH (if returning via Deception Pass)

LISTED AUTHORIZED PERSONS (Must be at least 2l years of age)

A student who wishes to return to the districlin a private vehicte must have written permission on file from his or her parent or guardian. Prior to being released, the Coach must be notified that the student will be leaving in a private vehicte, and only with those person(s) authorized on file or listed here. My student has permission to be released ONLY to these authorized person(s) named below after an away athletic/activities events (please add contact number)

ACKNOWLEDGEMENT AND AGREEMENT of the Ath letic/Go-Gu rr¡cu lar Contract BY OUR SIGNATURES BELOW:

complete.

Activities booklet in its entirety. athlete and/or the co-curricular participant, including ALL listed below: . GSD Concussion and sudden cardiac Arrest lnformation . WIAA Eligibility . Go-Gurricular/Athletic Code & Eligibility AcknowledgemenUAgreement Contract . Physical Examination (All physicals need to cover the entire sports season)

@

Student's Signature

Date

@ ParenUGuard ian

S ig

Date

nature

CO-GURRICULAR/ATHLETIC GLEARANCE TO BE COMPETED BY THE ATHLETIC OFFICE Co-Curricular/Athletic Form Signed ASB

Paid I

I

Participation Fee Paid (indicate paid sporUactivity) NOTES:

CSD/FES/HS/RS

PHYSICAL(Exp.date CC Winter

CC Fall

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I

I

)

CC SPring

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