MCCPS Athletics - Student Eligibility
Student Information
Student Name
*
Date of Birth
*
/
Month
/
Day
Year
Date
Grade
*
Sex
School
Sport
List previous injuries or pathological conditions
Has the student ever experienced a traumatic head injury (a blow to the head)?
Yes
No
If yes, when? Dates (month/year)
Has the student ever received medical attention for a head injury?
Yes
No
If yes, when? Dates (month/year)
If yes, please describe the circumstances:
Was the student diagnosed with a concussion?
Yes
No
If yes, when? Dates (month/year)
Duration of Symptoms (such as headache, difficulty concentrating, fatigue) for most recent concussion:
Student/Athlete Signature
*
Clear
Parent/Guardian Information
Emergency Contacts, Family Medical information
Parent/Guardian Name
*
Today's Date
*
/
Month
/
Day
Year
Date
Phone Number
*
Email
*
example@example.com
Address
*
Emergency Contact NAME
*
Emergency Contact PHONE NUMBER
*
Family Doctor Name
*
Family Doctor Phone Number
*
Family Medical Insurance Policy No.
*
Parent/Guardian Signature
*
Clear
By signing this form, you acknowledge that you (and your student) have read the Athletic Policies and Information Document, located on our website.
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