KEARNEY SCHOOL DISTRICT ACTIVITY COMMITMENT FORM
2022/2023 School Year
Street Address Line 2
State / Province
Postal / Zip Code
Parent / Guardian Name
Prior to participating in and MSHSAA activity each student must:
Successfully pass a PRE-PARTICIPATION PHYSICAL EVALUATION
PHYSICAL EXAMINATION FORM by a registered physician and the copy of such examination must be
on file in the office of the Activities Director.
Physical exam is valid for 2 years from the date of the exam. Exception is if physician notes that the physical is good for 1 year.
Have parents/guardians and student signatures.
Return this Activity Commitment form completed or sign online with a digital signature. A signed copy of
the MSHSAA PRE-PARTICIPATION DOCUMENTATION - ANNUAL REQUIREMENTS must be submitted to
the Activities Director office. This form is only good for the current school year.
As a school's student
participating voluntarily in interscholastic activities;
I understand that
I have read the 2022/2023 KEARNEY SCHOOL DISTRICT STUDENT ACTIVITIES HANDBOOK and
understand what the Kearney School District expects from me in regards to sportsmanship, citizenship.
scholastics, and staying free from drug/alcohol/tobacco use and gambling while enrolled in this school.
I understand the consequences for breaking school policy and I will not do so while a Kearney School
will be held responsible for all equipment issued to me throughout the season, will return such
equipment at the conclusion of the season and will pay the current replacement cost for any of the
equipment not accounted for by me or damaged at the end of the season.
I acknowledge that have been properly advised. cautioned. and warned by the administrative and
coaching personnel of the school district that I am exposing myself to the risk of injury, disease, including
but not limited to the risk of sprains, fractures and ligament and/or cartilage damage which could result in
a temporary or permanent. partial, or incomplete impairment in the use of my limbs, brain damage.
paralysis, or even death. Having been so cautioned and warned, it is still my desire to participate in
activities and to do so with full knowledge and understanding of the risk of injury.
We understand that open gym/field participation is voluntary and a privilege, not a right. This privilege
may be revoked at any time based on the discretion of the administration and board of education. The
privilege may be revoked for many reasons, including but not limited to, deficiency in the student's
grades, poor behavior during school hours or during open gym.
PARENT/GUARDIAN AND STUDENT SIGNATURE (Concussion Materials)
We received and read the MSHSAA materials on Concussion, which includes information on and
definition of a concussion, symptoms of a concussion, what to do if you have a concussion, and how to
prevent a concussion If you need a copy of the MSHSAA Concussion information packet click here or
see the Athletic office for a copy of the Handout.
A PARENT’S / GUARDIAN’S GUIDE TO CONCUSSION
Student School Email Address
Signature of Student
Parent Email Address
Signature of Parent(s) or Guardian
Please make a copy of this completed form and all physical exam paperwork for your records.
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