Fill - Free fillable MSHSAA PRE-PARTICIPATION DOCUMENTATION ANNUAL REQUIREMENTS (RenWeb) PDF form

Revised 6/2020

MSHSAA PRE-PARTICIPATION DOCUMENTATION – ANNUAL REQUIREMENTS

INTERIM MEDICAL HISTORY

Note: Complete and sign this form (with your parents if younger than 18).

Note: An injury or medical condition results in a separate medical release.

Name:

Date of Birth:

Date:

Sex assigned at birth (F, M or intersex):

How do you identify your gender? (F, M or other):

List past and current medical conditions:

Have you had surgery since your last Pre-Participation Physical Examination (physical)? If yes, list those surgical procedures:

Medicines and supplements: List all current prescriptions, over-the-counter medicines and supplements (herbal and nutritional):

Do you have any allergies? If yes, please list all of your allergies (i.e., medicines, pollens, food, stinging insects):

Have you been diagnosed with any medical or health condition since your last PPE (physical)? If yes, please describe:

I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete and correct.

Signature of Athlete:

Signature of Parent(s) or Guardian:

Date:

PARENT PERMISSION (Authorization for Treatment, Release of Medical Information, and Insurance Information)

Informed Consent: By its nature, participation in interscholastic athletics includes risk of serious bodily injury and transmission of infectious disease

such as HIV, Hepatitis B, severe acute respiratory syndrome (COVID-19) and/or any mutation or variation thereof. 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

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 RISK DESCRIBED IN THIS WARNING SHOULD

NOT SIGN THIS FORM. STUDENTS MAY NOT PARTICIPATE IN MSHSAA- SPONSORED SPORT WITHOUT THE STUDENT’S AND

PARENT’S/GUARDIAN/S SIGNATURE.

I understand that in the case of injury or illness requiring transportation to a health care facility, 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.

We hereby give our consent for the above student to represent his/her school in interscholastic athletics. We also give our consent for him/her to

accompany the team on trips and will not hold the school responsible in case of accident, injury or illness whether it be en route to or from another

school or during practice or an interscholastic contest; and we hereby agree to hold the school district of which this school is a part and the MSHSAA,

their employees, agents, representatives, coaches, and volunteers harmless from any and all liability, actions, causes of action, debts, claims, or

demands of every kind and nature whatsoever which may arise by or in connection with participation by my child/ward in any activities related to the

interscholastic program of his/her school.

In the event of an emergency or when the Parent(s) or Guardian is unable to directly supervise health care services needed by the student for injuries or

illnesses sustained at any athletic practice, conditioning exercise or contest, I also give my consent to the rendering of necessary health care services

for the student by a qualified provider (QP) covering the athletic practice, conditioning exercise or contest, including an athletic trainer, physician,

physician assistant, nurse practitioner or other medically-trained professional licensed by the State of Missouri (or the state in which the student injury or

illness occurs) and who is acting in accordance with the scope of practice under their designated state license and any other requirement imposed by

state law. In emergency situations, the QP may also be a certified paramedic or emergency medical technician for the purpose of providing emergency

health care and transport. Health care services are defined as services including, but not limited to, evaluation, diagnosis, first aid, emergency care,

stabilization, treatment and referral. I further authorize the QP who provides such health care services to disclose such information about the student’s

injury or illness, diagnosis, care and treatment in the professional judgment of the QP to the student’s athletic director, coaches, school nurse and any

classroom teacher required to provide academic accommodation to assure the student’s recovery and safe return to activity. If the Parent(s) or Guardian

believes that the student is in need of further evaluation, treatment, rehabilitation or health care services for the injury or illness, the student may be

treated by the physician or provider of his or her choice.

To enable the MSHSAA to determine whether the herein named student is eligible to participate in interscholastic athletics in the MSHSAA member

school, I consent to the release of any and all portions of school record files to MSHSAA, beginning with seventh grade, of the herein named student,

specifically including, without limiting the generality of the foregoing, birth and age records, name and residence address of parent(s) or guardian(s),

residence address of the student, academic work completed, grades received, and attendance data.

We confirm that this application for the above student to represent his/her school in interscholastic athletics is made with the understanding that we have

studied and understand the eligibility standards that our son/daughter must meet to represent his/her school and that he/she has not violated any of

them. We also understand that if our son/daughter does not meet the citizenship standards set by the school or if he/she is ejected from an

interscholastic contest because of an unsportsmanlike act, it could result in him/her not being allowed to participate in the next contest or suspension

from the team either temporarily or permanently.

I consent to the MSHSAA’s use of the herein named student’s name, likeness, and athletic-related information in reports of contests, promotional

literature of the Association and other materials and releases related to interscholastic athletics.

We further state that we have completed that part of this certificate which requires us to list all previous injuries or additional conditions that are known to

us which may affect this athlete's performance or treatment and we certify that it is correct and complete.

The MSHSAA By-Laws provide that a student shall not be permitted to practice or compete for a school until it has verification that he/she has basic

health/accident insurance coverage, which includes athletics. Our son/daughter is covered by basic health/accident insurance for the current school

year as indicated below:

Name of Insurance Company:

Policy Number:

Signature of Parent(s) or Guardian:

Date:

Has this student incurred a medical condition since their last physical examination?

□ Yes □ No

STUDENT AGREEMENT (Regarding Conditions for Participation)

This application to represent my school in interscholastic athletics is entirely voluntary on my part and is made with the understanding that I have studied

and understand the eligibility standards that I must meet to represent my school and that I have not violated any of them.

I have read, understand, and acknowledge receipt of the MSHSAA brochure entitled “How to Maintain and Protect Your High School Eligibility,” which

contains a summary of the eligibility rules of the MSHSAA. (I understand that a copy of the MSHSAA Handbook is on file with the principal and athletic

administrator and that I may review it in its entirety, if I so choose. All MSHSAA by-laws and regulations from the Handbook are also posted on the

MSHSAA website at www.mshsaa.org).

I understand that a MSHSAA member school must adhere to all rules and regulations that pertain to school-sponsored, interscholastic athletics

programs, and I acknowledge that local rules may be more stringent than MSHSAA rules.

I also understand that if I do not meet the citizenship standards set by the school or if I am ejected from an interscholastic contest because of an

unsportsmanlike act, it could result in me not being allowed to participate in the next contest or suspension from the team either temporarily or

permanently.

I understand that if I drop a class, take course work through Post -Secondary Enrollment Option, Credit Flexibility, or other educational options, this

action could affect compliance with MSHSAA academic standards and my eligibility.

I understand that participation in interscholastic athletics is a privilege and not a right. As a student athlete, 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 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.

I have completed and/or verified that part of this certificate which requires me to list all previous injuries or additional conditions that are known to me

which may affect my performance in so representing my school, and I verify that it is correct and complete.

Signature of Athlete:

Date:

Have you experienced a medical condition since your last physical examination?

□ Yes □ No

PARENT AND STUDENT SIGNATURE (Concussion Materials)

I accept responsibility for reporting all injuries and illnesses to my school and medical staff (athletic trainer/team physician) including any signs and

symptoms of a CONCUSSION. I have received and read the MSHSAA materials on Concussions, which includes information on the definition of a

concussion, symptoms of a concussion, what to do if I have a concussion and how to prevent a concussion. I will inform my school and athletic

trainer/team physician immediately if I experience any of these symptoms or if I witness a teammate with these symptoms.

Signature of Athlete:

Date:

Signature of Parent(s) or Guardian:

Date:

EMERGENCY CONTACT INFORMATION

Parent(s) or Guardian

Address

Phone Number

Name of Contact

Relationship to Athlete

Phone Number

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MSHSAA PRE-PARTICIPATION DOCUMENTATION ANNUAL REQUIREMENTS (RenWeb)

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