UXBRIDGE MIDDLE / HIGH SCHOOL CLEARANCE FOR ATHLETIC TEAM PARTICIPATION

NAME:______________________________ AGE:______ DATE OF BIRTH:___________ ADDRESS:_____________________________________ TELEPHONE:_______________ YEAR OF GRADUATION:__________ SPORT:________________ STUDENT HAS READ ATHLETIC AGREEMENT FORM:____________________ _______ Student Signature Date PARENT HAS READ ATHLETIC AGREEMENT FORM:______________________ ______ Parent Signature Date ATHLETIC FEE SUBMITTED __________________________ Coachs Signature __________________________ Nurses Signature __________________________ School Administration Signature

PHYSICAL EXAM ON FILE-UP TO DATE

ACADEMIC ELIGIBILITY CHECK

Massachusetts State Law requires that parents be made aware of the dangers of head injuries and the signs and symptoms of a concussion. This information is available through our website www.uxbridgehighschool.net. **Please initial: ____I have read and understood the signs and symptoms of a head injury and/or concussion. ____ I understand the importance of seeking immediate medical attention for my son or daughter in the chance that he/she shows any of these signs or symptoms. ____ I understand that once a diagnosis of a concussion or head injury has been made, every student athlete must follow a gradual return to play protocol under the care of a physician. This written clearance note must be given to the school nurse before any return to play. Has your son/daughter ever sustained a head injury that has resulted in a diagnosis of a concussion? YES or NO If Yes, when?____________________

*Student athlete must complete this form to participate.