FIFE SCHOOL DISTRICT

PARENT/STUDENT ACTIVITY PARTICIPATION STATEMENT

Student Name: _____________________________________________________________________

Address:___________________________________________________________________________

Parent/Guardian:_____________________________________ Home Phone:_____________________

Do you live within Fife School District boundaries?   _____Yes _____No

Do you live with your parent(s) and/or legal guardian? _____Yes _____No

Have you attended school in a district other than the Fife School District , within the past 12 months? If so, please explain.

            ______Yes _____No

Did you attend school full time last semester? _____Yes _____No

Indicate the calendar year in which you enrolled in the 8 th grade: __________

I passed _____credits last semester with a _______ GPA.

***Athletes not meeting all of the above criteria are not automatically exempt from participation in athletics at Fife High School . However, they may be subject to an eligibility hearing, conducted by the WIAA, prior to receiving initial clearance.

I have read the statements concerning the Notification of the Potential for Injury, the Notice of Need for Athletic Insurance Coverage, and the Activity Code of Conduct. We agree to abide by the stated guidelines during our entire high school career.

Student's Signature____________________________________________________

Parent's/Legal Guardian's Signature__________________________________________

Date_______________________

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PHYSICAL EXAMINATION NOTIFICATION

As regulated by WIAA, every student who participates in interscholastic athletics, cheer staff, or dance must have passed a physical examination from a licensed medical physician prior to participation each 13 month period. Incoming freshman students are required to obtain a new physical examination prior to registering for athletics.

The school in which the participating student is enrolled must have on file this prepared form from the examining physician certifying that his/her physical condition is adequate for the activity or activities in which he/she is participating.

In addition to the physical examination, a participating student must present to school officials a physician's release to resume participation following an illness and/or injury which is serious enough to require professional medical care.

FIFE SCHOOL DISTRICT

NOTIFICATION OF POTENTIAL FOR INJURY

STUDENT

  I understand that there is a risk of injury in athletics, cheer, and dance. I understand that the dangers and risks of athletics, cheer, and dance include, but are not limited to, serious neck and/or spinal injuries which may result in brain damage, paraplegia, quadriplegia, serious injury to virtually all organs and/or bones, and in some cases death.

  I have read the above and recognize the dangers of participating in athletics, cheer, and dance. I also recognize the importance of following the instructions of the coaching staff regarding safe playing techniques, training, and other team rules, etc., and agree to obey such instructions. I recognize that Fife School District athletics will have top priority demonstrated by a commitment to practices and contest as directed by the coaches.

PARENT   

I realize that participation in atheltics, cheer, and dance can involve MANY RISKS OF INJURY, including but not limited to those risks listed in the student section.

  I hereby grant permission for my child to participate in athletics, cheer, or dance . I agree that the Fife School District and/or authorized employees of said District shall not be held liable for accidents or injuries received by my son/daughter while engaged in athletics, cheer, or dance sponsored by the District. I further agree that the Fife School District , authorized employees or student organizations will not be responsible for payment of medical service resulting from such accidents or injuries.

NOTIFICATION OF NEED OF ATHLETIC INSURANCE COVERAGE.

  I, the undersigned, understand that the above named student should not participate in interscholastic athletics, cheer, or dance unless he/she is covered by accident insurance. We have accident insurance that will cover interscholastic athletics, cheer, and dance or we know we can purchase school insurance from the School District in the main office. We accept full responsibility for the cost of treatment for any injury our child may suffer while participating in an interscholastic athletic program. SPECIAL NOTE: Many plans do not cover interscholastic athletics.

ACTIVITY CODE OF CONDUCT

  It is the intention of Fife High School to inform all participants of atheltics, dance, and cheer of their responsibilities and risks of possible injury involved in extracurricular activities. The signatures indicate that the persons signing have read the material above and also the material that is contained in the Fife High School Activity Code within the Student Handbook. The signees agree to abide by this code.