Student First Name:
Student Last Name:
-- Male Female *
-- 7 8 9 10 11 12 *
Boys Track and Field
Girls Track and Field
Parent First Name:
Parent Last Name:
AUTHORIZED PERSON TO CONTACT IN CASE OF AN EMERGENCY
(GRANDFATHER, GRANDMOTHER, FAMILY FRIEND, ETC.)
Relationship to Student:
PRIMARY CARE DOCTOR INFORMATION
Parents or Legal Guardians: Please note below any health concerns, medications, or allergies that may be important for the coaches or athletic/activities director to know.
MSHSL ANNUAL SPORTS HEALTH QUESTIONNAIRE
Check off any boxes where the answer is YES.
Since your last Sports Qualifying Physical Exam or Sports Health Questionaire:
Has a doctor restricted your participation in sports for any reason without clearing you to return to sports?
Have you passed out or nearly passed out DURING or AFTER exercise?
Have you had discomfort, pain, tightness, or pressure in your chest during exercise?
Does your heart race or skip beats (irregular beats) during exercise?
Do you get light-headed or feel more short of breath during exercise?
Have you had an unexplained seizure?
Has anyone in your immediate family died suddenly and unexpectedly for no apparent reason?
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)?
Has anyone in your immediate family had instances of unexplained fainting, seizures, or near drowning?
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?
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?
Does anyone in your immediate family under age 50 have a heart problem, pacemaker, or implanted defibrillator?
Have you had mononucleosis (mono) within the last month?
Have you had a head injury or concussion that still has symptoms like continuing headaches?
Have you had numbness, tingling, weakness in, or inability to move your arms or legs after being hit or falling?
Date of Last Sports Qualifying Physical Exam (SQPE):
I do not know of any existing physical or additional health reason that would preclude participation in sports. I certify that the answers to the above questions are true and accurate and I approve participation in athletic activities.
Check each box to move forward
I have read, understand, and acknowledge receiving the 2017-2018 MSHSL Eligibility Brochure, which contains only a summary of the eligibility rules of the Minnesota State High School League.
I understand that a copy of the Official Handbook of the MSHSL is on file with the senior high school athletic director and or principal and that I may review it, in its entirety, if I so choose. The Official Handbook and MSHSL bylaws are also posted on the MSHSL website: www.MSHSL.org under Handbook.
We, the student and parent, have reviewed Concussion Management Recommendations for MSHSL Athletes contained in the 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 the statement through the completion of my high school eligibility.
Regardless of my age I agree to follow all of the MSHSL Bylaws in order to be eligible to represent my school in League-sponsored activities.
I further understand that a member school of the MSHSL must adhere to all of the rules and regulations that pertain to the League athletics/activities a school may sponsor and that local rules may be more stringent, and penalties more severe, than MSHSL 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. A student whose character or conduct violates the Student Code of Responsibilities or is suspended or expelled is not in good standing and is ineligible for a period of time as determined by the principal. While a student not in good standing, a student may not serve any penalty for MSHSL Bylaw violations.
Informed Consent: By its nature, participation in interscholastic athletics includes risk of injury and the transmission of infectious diseases such as HIV, Herpes and Hepatitis B and others. Although serious injuries are not common and the risk of HIV transmission is almost nonexistent in supervised school athletic programs, it is impossible to eliminate all risk. Participants have the responsibility to help reduce that risk. Participants must obey all safety rules, report all physical and hygiene problems to their coaches, follow a proper conditioning program, and inspect their own equipment daily. PARENTS, GUARDIANS OR STUDENTS WHO MAY NOT WISH TO ACCEPT THE RISK DESCRIBED IN THIS WARNING SHOULD NOT SIGN THIS FORM. STUDENTS MAY NOT PARTICIPATE IN AN MSHSL-SPONSORED ACTIVITY WITHOUT THE STUDENT’S AND PARENT’S/GUARDIAN’S SIGNATURE.
I consent to the athletic trainer or coach treating injuries and authorize them to discuss those injuries with and release any applicable medical information or records relating to those injuries to coaches, school staff and other qualified health care providers as deemed necessary within their scope of practice.
I further understand that in the case of injury or illness requiring transportation to a health care facility, that a reasonable attempt will be made to contact the parent or guardian in the case of the student-athlete being a minor, but that, if necessary, the student-athlete will be transported via ambulance to the nearest hospital.
By signing this we acknowledge that we have read the information contained in the MSHSL Eligibility Brochure and Statement.
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.
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.
We, the undersigned, feel we have adequate insurance protection for our Son/Daughter while practicing or participating in Interscholastic Sports.
SIGNATURE AND AUTHORIZATION
SEND on this form, you authorize that you are the legal parent of the student named in this form and that you recognize that this is your legal and binding electronic signature and that any fraud or inaccuracy will void this student's eligibility.
You must complete the security prompt below and hit send (only once).