EAGLE PEAK SCHOOL 2018-2019
SPORTS PARTICIPATION CHECKLIST
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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_____ 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.
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 ______________________________________________________________
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.
8601 West Rd, Redwood Valley, California, must be given prior to cancellation.
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.