BLAINE SCHOOL DISTRICT
REQUIREMENTS FOR PARTICIPATION/ELIGIBILITY

In order for a student to participate in any extra curricular activity, the student must have on file in the office a record of the following:
1) Physical examination with a physician's signature and date. A sports physical is valid for two (2) calendar years.
2) Emergency information form
3) Insurance coverage information, policy and number
4) Record of purchase of an ASB card.
5) Signature of student and parent/guardian signifying they have read, understood and accepted the athletic code handbook regulations

The athletic office will check WIAA eligibility standards for each athlete. A WIAA handbook is available in the Athletic Director’s office.

STUDENT/EMERGENCY INFORMATION:
Student Name: _________________________ Birth Date: ____/____/____ Age: ____ Grade: ____
Address: _____________________________________ City/Zip: __________________________
Parent/Guardian Name: _________________________ Home Phone: ______________________
Parent/Guardian Address: _______________________ Work/Cell #: _______________________
Doctor: ______________________ Dr. Phone: ________________
In case of emergency, when the parent/guardian cannot be notified, please contact:
Name: _______________________________________ Phone: ____________________
Name: _______________________________________ Phone: ____________________
List any known medical conditions staff should be aware of (i.e. diabetes, epilepsy):
________________________________________________________________________________
List any known allergies to medications: ________________________________________

ACCIDENT INSURANCE – PARENT/GUARDIAN RESPONSIBILITY:
I understand accident insurance is a requirement for participation in the Blaine School District’s athletic program. I recognize in case of injury to my son/daughter, the cost of the medical treatment is my responsibility and not the responsibility of the Blaine School District. I further understand my son/daughter must be covered by medical and dental insurance while participating in school athletics.

__ I have purchased insurance coverage with __________________________ (name of company)
Insurance Policy Number __________________________

SAFETY GUIDELINES:
Your son/daughter has chosen to participate in a Blaine School District athletic/activity program, which can be dangerous. Accidents can happen and the risk of serious injury, even death, does exist. Your signature below indicates you have been advised of and fully understand this danger.

RESIDENCE/TRANSFER: The student must be residing within the boundaries of the Blaine School District while living with their natural parents(s), parent of legal custody or court appointed guardian for one year. To the best of my knowledge my son/daughter meets this criteria: ___ YES ___ NO (conference with athletic director required)

PERSONAL ITEMS: The Student athlete is responsible for safeguarding all personal belongings during practices and trips/events. The Blaine School District is not responsible for lost or stolen items. Items should not be left on school buses, as they do not lock.

CO-CURRICULAR CODE CONSENT: We have read and understand this document, and will honor the code, consenting to the conditions set forth, and provide permission for law enforcement agencies to release to the Blaine School District information related to potential violation(s). We understand these expectations apply throughout the student’s Blaine School District experience.

PARENT/GUARDIAN SIGNATURE: ________________________ DATE: ______________

STUDENT SIGNATURE: ________________________________ DATE: _______________