Athletic Eligibility Form - Step 3: Fill Out the Eligibility Form

Step 3: Athletic Eligibility Statement, School Enrollment History & Health Questionnaire


YOU MUST FILL OUT THE CHECKLIST FOR STUDENT ELIGIBILITY
		1. Making academic progress toward graduation.
		2. Have not and will not use or possess tobacco or alcoholic beverages, use, consume, have in possession, buy, sell or give away any other controlled substance, including steroids, or drug paraphernalia.
		3. Both the student and parent have reviewed the concussion management information contained in the Eligibility Brochure and found the following website: www.cdc.gov/concussion
		4. Physical exam within the last 13 months on file with the school.

REFUND POLICY - 1. When injury or illness prevents continuation in the activity, a refund will be made (provided the injury or illness is substantiated by a physician's statement) up until the time of the first contest, or after 10 days which ever occurs first. 2. When a transfer is made out of Bourne School District up until the first contest. 3. NO refunds will be award for a students who quits an activity, dismissed from an activity because of disciplinary reasons or eligibility infractions. 4. NO refunds will be given after the first 10 days or first contest, whichever comes first. 5. Please write a Refund Request letter, and return it to the Athletic Department for a refund.



Student/Participant Information:

Sport Participating In:	*

Age:	*

Gender:

Birthdate:	*

Address:	*

Address:

City:	*

State:

Zip:	*

Home Phone:	*

Date of Last Sports Physical Exam:

List All School Enrolled in During the Following School Years:

2019-2020:

2020-2021:

2021-2022:

Parent/Guardian 1 Information:

Guardian 1 Name:	*

Guardian 1 Relationship to Student:	*

Guardian 1 Cell Phone Number:	*

Guardian 1 Email:

Parent/Guardian 2 Information:

Guardian 2 Relationship to Student:

Guardian 2 Name:

Guardian 2 Cell Phone:

Guardian 2 Email:



ANSWER THE FOLLOWING as YES or NO 'Since the student's last Sports Qualifying Physical Exam or Sports Health Questionaire' (I.E. If last physical was last month then answer these questions AS OF the date of the physical last month):

Check off any boxes where the answer is YES.
		1. Has a doctor restricted your participation in sports for any reason without clearing you to return to sports?

IMPORTANT HEART HEALTH QUESTIONS ABOUT YOU
		2. Have you passed out or nearly passed out DURING or AFTER exercise?
		3. Have you had discomfort, pain, tightness, or pressure in your chest during exercise?
		4. Does your heart race or skip beats (irregular beats) during exercise?
		5. Do you get light-headed or feel more short of breath during exercise?
		6. Have you had an unexplained seizure?

IMPORTANT HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
		7. Has anyone in your immediate family died suddenly and unexpectedly for no apparent reason?
		8. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 (including drowning, car accident, or Sudden Infant Death Syndrome)?
		9. Has anyone in your immediate family had instances of unexplained fainting, seizures, or near drowning?
		10. Has anyone in your immediate family developed hypertrophic cardioimyopathy, Marfan Syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT Syndrome, short QT Syndrome, Brugada Syndrome, or catecholaminergic polymorphic ventricular tachycardia?
		11. Has anyone in your immediate family been diagnosed with Marfan Syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT Syndrome, short QT Syndrome, Brugada Syndrome, or catecholaminergic polymorphic ventricular tachycardia?
		12. Does anyone in your immediate family under age 50 have a heart problem, pacemaker, or implanted defibrillator?

MEDICAL RISK QUESTIONS
		13. Have you had mononucleosis (mono) within the last month?
		14. Have you had a head injury or concussion that still has symptoms like continuing headaches, concentration problems or memory loss?
		15. Have you had numbness, tingling, weakness in, or inability to move your arms or legs after being hit or falling?

Parents or Legal Guardians - please note: • A “Yes” answer to any of the above questions will require a clearance note from a physician prior to participation.

Please enter Emergency Information: Insurance Company name, Policy#, Dr. Name/Clinic:	*

Please list emergency contact #1 work, home, and cell phone numbers.	*

Please enter Emergency Contact #2 Home, Work, and Cell phone numbers.

Please enter any of the following Health Concerns: Diabetes, Seizures, Asthma or Allergies. Please list Allergies



BHS Athletic Eligibility Statement • I have read, understand, and acknowledge receiving the Athletic Eligibility Brochure, which contains a summary of the eligibility rules of the Bourne High School. I understand that a copy of the Official Handbook of the BHS is on file with the high school principal and that I may review it, in its entirety, if I so choose. The Official Handbook and BHS bylaws are also posted on the BHS Web site: www.bourne.k12.ma.us for my review. We, the student and parent, have reviewed Concussion Management Recommendations for BHS Athletes contained in Eligibility Brochure and on the following website: www.cdc.gov/concussion • I understand that once I sign the eligibility statement all eligibility rules apply: - Twelve (12) months of the year; - Whether I am currently participating or not; - Continuously from the first signing of this statement through the completion of my high school eligibility. Regardless of my age I agree to follow all of the BHS Bylaws in order to be eligible to represent my school in League-sponsored activities. • I further understand that a member school of the SCC must adhere to all of the rules and regulations that pertain to the League athletic activities a school may sponsor and that local rules may be more stringent, and penalties more severe, than SCC rules. STUDENT CODE OF RESPONSIBILITIES • As a student participating in my school’s interscholastic activities, I understand and accept the following responsibilities: - I will respect the rights and beliefs of others and will treat others with courtesy and consideration. - I will be fully responsible for my own actions and the consequences of my actions. - I will respect the property of others. - I will respect and obey the rules of my school and the laws of my community, state and country. - I will show respect to those who are responsible for enforcing the rules of my school and the laws of my community, state and country. *By signing this we acknowledge that we have read the information contained in the BHS Eligibility Brochure and Statement. The student/parent authorizes the release of documents and other pertinent information by the school in order to determine student eligibility. In addition, the student/parent understands and agrees that public information shall include names and pictures of students participating in or attending extra-curricular activities, school events, and High School League activities or events.

I do not know of any existing physical or additional health reason that would preclude participation in sports. I acknowledge that I have read the Athletic Eligibility Brochure and Statement. I certify that the answers to the above questions are true and accurate and I approve participation in athletic activities.

Parent/Guardian's First & Last Name:	*

Student's First & Last Name:	*

I/we acknowledge the electronic signature confirms I/we have read and reviewed the information contained in the contents of the Eligibility Brochure and Statement. I/we also acknowledge this electronic signature has the same legal effect, validity, and enforceability as a signature in a non-electronic form.

Send a copy of the completed form to this email address :

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