VARSITY & JV INTERSCHOLASTIC ATHLETICS PARTICIPATION FORM
Fall 2017

PLEASE USE PARENT/GUARDIAN EMAIL ADDRESS WHEN COMPLETING THIS FORM.

Email address
Additional email address (optional)
Your answer
Ichabod Crane Central School District
Athlete's Last Name
Your answer
Athlete's First Name
Your answer
Date of Birth
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Grade (Fall 2017)
**7th & 8th graders who have appropriate experience and ability may sign up for the Athletic Placement Process (APP). This process includes a developmental screening and physical fitness test to determine eligibility to try-out for a JV or Varsity level team. Detailed information about this process will be provided to your child to bring home by the Middle School Physical Education Staff once they are signed up.
Athletic Activity
MEDICAL HISTORY
Date of last Health appraisal
New York State regulation requires a physical examination in order to participate in athletic programs, beginning with the first day of tryouts. Physicals are valid for a period of 12 consecutive months. Applicants will be notified by the school nurse should a updated physical on file be necessary. All updated physicals should be turned in to the school nurse. ** IF YOU HAVE A PHYSICAL SCHEDULE FOR A FUTURE DATE, PLEASE PUT THAT DATE DOWN **
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History Since Last Medical Exam
1. Any injuries requiring medical attention?
2. Any illness lasting more than 5 days?
3. Taking any medicine or under a physician's care at this time?
4. Any feeling of faintness, dizziness, or fatigue after heavy exertion?
5. Wearing glasses or contact lenses?
6. A surgical operation or fracture?
7. Treated in a hospital or emergency room?
8. Any reason why this person cannot participate in any sport?
9. Any know allergies?
10. Any chronic disease?
If YES to any of the above, describe:
Your answer
Permission
We understand clearly that the questions are asked in order to decide if this student is in a proper condition to participate in the athletic activity named at the top of this form. The answers are correct as of the date this form is signed. All answers will be kept confidential in your child's health record in the school health's office.

To my knowledge, there is no medical reason that my son/daughter cannot participate in interscholastic sports.

I give permission for my child to participate for the Spring 2017 sports season in the sport indicated above, which includes being seen by a NYS Certified Athletic Trainer at no expense to the student.

Signature of Parent/Guardian
By adding your name this is your verified electronic signature
Your answer
Signature of Student
By adding your name this is your verified electronic signature
Your answer
Note: "Yes" answers to any of the questions above does not automatically disqualify the athlete from the activity indicated. This will require review and evaluation by the school physician.
A CONFIRMATION EMAIL WILL BE EMAILED TO YOU ONCE YOU SUBMIT THE FORM.
If you do not receive a confirmation in your email - check your SPAM Inbox and check to see you entered your email address correctly.
Tim Stewart, Director of Athletics
Email: tstewart@ichabodcrane.org Phone: (518) 758-7575 x4007
A copy of your responses will be emailed to the address you provided.
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