EAGLE PEAK SCHOOL 2018-2019

SPORTS PARTICIPATION CHECKLIST

_______________________     ______        __________         _____

Student’s Name                           Grade             Sports                    I.D. #

I have read and understand the following documents that are available on the (PLEASE INITIAL NEXT TO EACH DOCUMENT):

Athlete                 Parent/Guardian             

________           ________           Health Examination and Parent Consent

________           ________           CIF Code of Conduct

________           ________           UUSD Extra-Curricular Rules & Regs/Student Contract

________           ________           Acknowledgement/Assumption of Potential Risk

________           ________           NCS Ejection Policy

Signature of Parent         ____________________________  Date   __________________

Signature of Athlete       ____________________________  Date  __________________

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PARTICIPATION RECOMMENDATIONS

_____ 1. There were no history or physical findings on this exam which would prohibit this student from participating in competitive athletics.

_____ 2.  This student should have the following health problems evaluated or treated prior to participating in competitive athletics.

_____ 3.  This student has health problems which would prohibit him or her from participating in competitive athletics.

PHYSICIAN’S STATEMENT CERTIFICATION

Are there apparent cavities in teeth?    _____ Yes       _____ No

Is there a bridge or false teeth?            _____  Yes        _____ No

Has the above had any injury or physical condition that should be watched? _____ If yes, please list.

I hereby certify that ____________________________ was examined by me on ____________  20______

and found physically fit to participate in sports in the school year 2018 – 2019.

Physician’s Signature __________________________________  Date ____________________

Please Print Name ______________________________________________________________

RETURN THE PHYSICIAN’S CERTIFICATION & PAGES 1-3, PARENT ASSURANCE OF INSURANCE COVERAGE, & CONCUSSION PARENT ATHLETE FORM TO THE

EAGLE PEAK MIDDLE SCHOOL OFFICE

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PARENT ASSURANCE OF INSURANCE COVERAGE

Students taking part in the school athletic program must be fully insured against injury and death. You must have insurance covering sports including contact football, for your child. If you do not have insurance, you may obtain it through your own agent or purchase (student) insurance available to all students.  See the Athletic Director for information.

       NAME OF INSURANCE COMPANY                             POLICY NO.

1. Ten (10 days written notice to the Principal of Eagle Peak School, Ukiah Unified School District,

8601 West Rd, Redwood Valley, California, must be given prior to cancellation.

2. Deductible insurance does not fulfill the legal requirements for participation.

I will maintain this coverage during the current school year or will immediately notify the school if the coverage terminates or does not meet the stated requirements.