Adopted: November 1986
Revised: November 2023
Student______________________________________
Date______________________________________________
Middle School _______________________________________
Grade____________
Sport______________________________________________
Attendance Area High School
Participation High School
A. Options discussed:
B. The following members of this committee met and considered the above-named student’s request to participate in a junior varsity or varsity level athletic activity.
Signature Title
___________________________________________ Middle School Principal
___________________________________________ High School Principal
___________________________________________ Middle School Athletic Director
___________________________________________ High School Athletic Director
___________________________________________ Middle School Head Coach
___________________________________________ High School Head Coach
___________________________________________ School Psychologist
C. We recommend/do not recommend (circle one) that the above-named student be given the opportunity to participate on a junior varsity or varsity level team.
D. Reasons for recommendation:
_____________________________________________
Signature of middle school principal
I agree/disagree (circle one) with the committee’s recommendation.
_____________________________________________
Signature of director of secondary education