Student Athlete Medical Eligibility Form
Student Athlete Medical Eligibility Form
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Grade Level
*
Please Select
6th Grade
7th Grade
8th Grade
9th Grade (Freshman)
10th Grade (Sophomore)
11th Grade (Junior)
12th Grade (Senior)
School Name
*
Sport(s) Participating In
*
Basketball
Soccer
Football
Baseball/Softball
Track & Field
Volleyball
Other
Primary Contact Email
*
example@example.com
Primary Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name & Relationship
*
Has the student experienced any injury or illness in the past 12 months that could affect participation?
*
No
Yes (please explain below)
Submit
Should be Empty: