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Series 604. - Middle School Annual Sports Health Questionnaire, Participation Release and Fees


Student's Name                                                                                                           Grade                        

Check the sport(s) you are paying for now; in accordance with Administrative Regulation 507.2AR. The fee for each sport is $110; students may participate in only one sport per season. If a student quits an activity within five days, the fee will be refunded.

       Fall Season                                         Winter Season I                                      Spring Season

            Girls Soccer                                            Girls Basketball                                       Boys Track

            Boys Soccer                                            Boys Wrestling                                        Girls Track

            Girls Tennis                                   Winter Season II                                              Boys Tennis

            Girls Volleyball                                         Boys Basketball              

            Boys Cross Country                        Winter Season III                                

            Girls Cross Country                                  Boys Swimming

                                                                         Girls Swimming

Grades 7-12, High School Programs – Students who want to try out for these sports must register and pay at the high school in their attendance area using this form. The fee for each adapted sport is $110; all others are $149.      

       Fall Season                                          Winter Season                                          Spring Season

            Adapted Soccer, CI/PI                               Girls Gymnastics                                     Girls Softball

              Nordic Skiing                                          Adapted Softball, CI/PI

              Girls Hockey

              Adapted Floor Hockey, CI/PI

NOTE TO STUDENTS AND PARENTS/GUARDIANS: Middle school students participating in high school athletics will not be released early from school to attend practice, but may be released early to attend competitions. Transportation from middle school to high school is the responsibility of the parent.

NOTE TO STUDENTS AND PARENTS/GUARDIANS: In order to participate in any practices and games, a student must have a valid sports-qualifying physical examination form on file at his or her school. Registrations will NOT be accepted until a sports-qualifying physical form is turned in or on file. If the student recently had a sports-qualifying physical, attach a signed note from the physician with the date of the physical or a copy of the physical examination form.

Do you have a physical form from within the last three years on file at school?     _____ Yes    _____ No          If you recently had a physical, please return the form along with the participation fee.

The following questions must be answered by the parent or guardian:                                  (please circle)

1.   Has the student been hospitalized since the above physical examination?                         YES       NO

2.   Has the student had a major injury since the above physical examination?                        YES       NO

3.   Has the student required medication on a daily or episodic routine?                                 YES       NO

      (Example:  insulin daily or asthma medication with an attack)

4.   Has the student been knocked unconscious at any time within the past 12 months?          YES       NO

5.   Has the student had a tetanus (lockjaw) booster within the last 10 years?                         YES       NO

6.   Has the student had one or more severe allergic reactions?                                              YES       NO

7.   Do you know of or believe there is any health reason why this student should not              YES       NO

      participate in middle school athletics?  If so, why?                                                                                

The undersigned, herewith,

A.   Grants the above-named student permission to participate in school athletic activities;

B.   Grants permission to take the student on supervised trips connected with athletic activities;

C.   Understands that the student must refrain from practice or play during medical treatment until he
or she is given a written permit by a physician to resume participation;

D.   Understands that middle schools follow the guidelines of the Minnesota State High School League as they pertain to drugs and alcohol;

E.   Certifies the parent/guardian and the student have received and read the CDC concussion fact sheet found on the reverse of this document, and

F.   Certifies that the answers to the above questions are correct and true.

Parent/guardian’s permit, health questionnaire and participation fee must be completed, signed and placed on file in the school office before the student will be permitted to practice or play.

I am enclosing $                     (checks are payable to the school)


Parent or guardian signature                                                 Student signature


Received by                                                    Date                                       Amount received