Athletic Registration Form


Create Instructions for this form
 
STUDENT INFORMATION:
 
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PARENT/GUARDIAN INFORMATION
 
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AUTHORIZED PERSON TO CONTACT IN CASE OF AN EMERGENCY
I.E.- Grandfather, Grandmother, family friend
 
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PRIMARY CARE DOCTOR INFORMATION 
 
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MSHSL ANNUAL SPORTS HEALTH QUESTIONNAIRE

Check Yes or No Box for each question.

In the last year, since your last complete Sports Qualifying Physical Exam with your physician or your Year 2 Annual Health Questionnaire, have you had any changes to the following questions:
 
1. In the last year, has a doctor restricted your participation in sports for any reason without clearing you to return to sports?  
     
     
 
IMPORTANT HEART HEALTH QUESTIONS ABOUT YOU IN THE LAST YEAR
 
2. In the last year, have you passed out or nearly passed out during or after exercise?  
     
     
 
3. In the last year, have you had discomfort, pain, tightness, or pressure in your chest during exercise?  
     
     
 
4. In the last year, does your heart race or skip beats (irregular beats) during exercise?  
     
     
 
5. In the last year, do you get light-headed or feel more short of breath than expected during exercise?  
     
     
 
6. In the last year, have you had an unexplained seizure?  
     
     
 
IMPORTANT HEART HEALTH QUESTIONS ABOUT YOUR FAMILY IN THE LAST YEAR
 
7. In the last year, has anyone in your immediate family died suddenly and unexpectedly for no apparent reason?  
     
     
 
8. In the last year, has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 (including an unexplained drowning, an unexplained car accident, or Sudden Infant Death Syndrome)?  
     
     
 
9. In the last year, has anyone in your immediate family had instances of unexplained fainting, seizures, or near drowning?  
     
     
 
10. In the last year, has anyone in your immediate family developed hypertrophic cardiomyopathy, Marfan Syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT Syndrome, short QT Syndrome, Brugada Syndrome, or catecholaminergic polymorphic ventricular tachycardia?  
     
     
 
11. In the last year, has anyone in your immediate family been diagnosed with Marfan Syndrome, arrhythmogenic right ventricular cardiomyopathy,long or short QT Syndrome, Brugada Syndrome, or catecholaminergic polymorphic ventricular tachycardia?  
     
     
 
12. In the last year, has anyone in your immediate family under age 50 had a heart problem, pacemaker, or implanted defibrillator?  
     
     
 
MEDICAL RISK QUESTIONS IN THE LAST YEAR
 
13. Have you had infectious mononucleosis (mono) within the last month?  
     
     
 
14. In the last year, have you had a head injury or concussion that still has symptoms like continuing headaches, concentration problems or memory problems?  
     
     
 
15. In the last year, have you had numbness, tingling, weakness in, or inability to move your arms or legs after being hit or falling?  
     
     
 
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2017-18 MSHSL Eligibility Statement
 
 
I have read, understand, and acknowledge receiving the 2017-2018 MSHSL Eligibility Brochure, which contains only a summary of the eligibility rules of the Minnesota State High School League. I understand that a copy of the Official Handbook of the MSHSL is on file with the senior high school athletic director and or principal and that I may review it, in its entirety, if I so choose. The Official Handbook and MSHSL bylaws are also posted on the MSHSL website: www.MSHSL.org under Handbook. 
     
 
We, the student and parent, have reviewed Concussion Management Recommendations for MSHSL Athletes contained in the Eligibility Brochure and on the following website: www.cdc.gov/concussion. 
     
 
I understand that once I sign the eligibility statement all eligibility rules apply: • Twelve (12) months of the year; • Whether I am currently participating or not; • Continuously from the first signing of the statement through the completion of my high school eligibility.  
     
 
Regardless of my age I agree to follow all of the MSHSL Bylaws in order to be eligible to represent my school in League-sponsored activities.  
     
 
I further understand that a member school of the MSHSL must adhere to all of the rules and regulations that pertain to the League athletics/activities a school may sponsor and that local rules may be more stringent, and penalties more severe, than MSHSL rules. 
     
 
STUDENT CODE OF RESPONSIBILITIES
 
 
As a student participating in my school’s interscholastic activities, 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 the 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. A student whose character or conduct violates the Student Code of Responsibilities or is suspended or expelled is not in good standing and is ineligible for a period of time as determined by the principal. While a student not in good standing, a student may not serve any penalty for MSHSL Bylaw violations.  
     
 
Informed Consent: By its nature, participation in interscholastic athletics includes risk of injury and the transmission of infectious diseases such as HIV, Herpes and Hepatitis B and others. 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 have the responsibility to help reduce that 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 THE RISK DESCRIBED IN THIS WARNING SHOULD NOT SIGN THIS FORM. STUDENTS MAY NOT PARTICIPATE IN AN MSHSL-SPONSORED ACTIVITY WITHOUT THE STUDENT’S AND PARENT’S/GUARDIAN’S SIGNATURE.  
     
 
I consent to the athletic trainer or coach treating injuries and authorize them to discuss those injuries with and release any applicable medical information or records relating to those injuries to coaches, school staff and other qualified health care providers as deemed necessary within their scope of practice. 
     
 
I further understand that in the case of injury or illness requiring transportation to a health care facility, that 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. 
     
 
By signing this we acknowledge that we have read the information contained in the MSHSL Eligibility Brochure and Statement.  
     
 
I/we acknowledge the electronic signature confirms I/we have read and reviewed the information contained in the contents of the Eligibility Brochure and Statement. I/we also acknowledge this electronic signature has the same legal effect, validity, and enforceability as a signature in a non-electronic form. 
     
 
The student/parent authorizes the release of documents and other pertinent information by the school in order to determine student eligibility.  In addition, the student/parent understands and agrees that public information shall include names and pictures of students participating in or attending extra-curricular activities, school events, and High School League activities or events.
 
 
 
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Kasson- Mantorville Public Schools
Athletics Parental Consent Form

Release from Liability and Indemnity Agreement

Medical Emergency Treatment Authorization

I/We do hereby CONSENT to my son/daughter's voluntary participation in athletic programs sponsored by the Kasson-Mantorville Public Schools (hereinafter referred to as the “voluntary sports programs”). I/We RELEASE and discharge TheKasson-MantorvilleSchool District, the Towns of Kasson and/or Mantorville and its departments, officers, employees, administration, school committee and agents (hereinafter collectively referred to as “Kasson-Mantorville”) from any and all claims, damages, losses, or expenses of whatever kind or nature which said minor may have or acquire arising out of or resulting from, directly or indirectly, his/her participation in the voluntary sports program.I/We furthermore agree to defend and IDEMNIFY Kasson-Mantorville against any claim, damage, loss or expense of whatever kind or nature that Kasson-Mantorville may have to pay that arises from said minor’s intentional, grossly negligent, or reckless acts or omissions while participating in the voluntary sports programs.

 I/We understand that sports in the voluntary sports programs are inherently dangerous activity and that there are genuine and serious risks to anyone who engages in this activity. Due to the nature of sport and physical activity, I/we understand that the risks involved include, without limitation, a full range of injuries, including potential catastrophic injury resulting in permanent paralysis, brain injury, or death.

 I/We hereby authorize Kasson-Mantorville's employee(s) or agent(s) who is supervising said minor to act on our behalf in authorizing and consenting to emergency medical care for said minor if he/she becomes ill or is injured while participating in the voluntary sports programs. This Authorization and Consent may be presented to the appropriate emergency medical staff at such time as emergency medical care is required. I/We hereby RELEASE and discharge Kasson-Mantorville from any and all claims of any nature whatsoever, which may arise out of the decision to provide emergency medical care.

 My signature below indicates that I/we have read this entire document and understood it completely.

 
 
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Kasson-Mantorville High School 
Fitness Center
Rules and Etiquette

 

A K-M Fitness Center membership includes access to: free weights (dumbbells), treadmills, ellipticals, rowing machines, functional trainers, stationary bikes, kettlebells, TRX suspension trainers, rings, resistance bands, medicine balls, slam balls, arc trainers, weight bars, benches, power racks, battle ropes, pull-up stations, monkey bar sets, olympic bars, box sets, curl bars, sandbags, TV access, music access, easy access, and exclusive member discounts on Community Education Fitness Classes.

  • Please carry your gym shoes.  Street shoes are NOT allowed in the Fitness Center.

  • Proper attire is required.  This includes closed toe shoes, t-shirts/tank top, exercise shorts/pants.  

  • No street shoes, jeans, open-toed shoes, or clothing with offensive wording will be allowed.  Revealing clothing is also not permitted.  Shirts must be worn at all times.  

  • Gym bags and jackets belong in the cubbies located directly inside the fitness center main entrance.  

  • Please do not store valuables on the floor or near equipment.

  • No vulgar or obscene language will be tolerated.  

  • Water and sports drinks must be consumed from containers with a lid.  No glass containers are allowed.  

  • Children under the age of 18 are not allowed to be in the fitness center.  K-M Students in Grades 7-12 are allowed in the Fitness Center during supervised hours 3:00-7:00 pm or with a K-M Activities Coach.

  • Please clean your machines after you are done using them.

  • Members are required to pick-up after themselves and discard trash and remove personal items from equipment when they are done with the machine.

  • There is a 30-minute time limit on all cardiovascular equipment if other members are waiting to use them.

  • Return all equipment to its place.

  • All barbells and dumbbells must be returned to the racks.

  • Take turns on the equipment when student and community programs are running.

  • Do not allow weights on machines to slam down.  Platforms are available for barbell lifts.

  • The staff are here to help during supervised hours.  Please ask for assistance if needed, or call K-M Community Education if you have questions.  

Cleanup Checklist

Before you leave the weight room please make sure the following are taken care of:

 
  • Weights are put back on plate racks (nothing left on the bar)

  • All Safety clamps are off the ground (hooked into the power lift station)

  • All benches are lying flat and pushed into their respective lift station

  • On each platform station, there are 1 light bar and 1 heavy bar

  • On each rack section, there are 2 heavy bars, 2 Ez bars, (either on rack or in tree)

  • Dumbbells are on the correct rack (light/medium/heavy)

There has been a substantial amount of time and money contributed to making this an excellent community fitness facility please respect those who utilize it.  

 

Thank you for your time in keeping our equipment neat and clean!


 
 
  I agree to these rules and terms. If I do not cooperate in the fitness center, I am aware that my Fitness Center privileges may be revoked at any time.  
     
 

 

SIGNATURE AND AUTHORIZATION

By clicking SEND on this form, you authorize that you are the legal parent of the student named in this form and that you recognize that this is your legal and binding electronic signature and that any fraud or inaccuracy will void this student's eligibility.
 




  Send a copy of the completed form to this email address : 


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