Pcs Form 4 1891 A – Fill Out and Use This PDF

Parent(s) or Guardian(s) Must Complete This Section

Are you an Administrative Transfer (Check One):

Yes __

No __

Birth Certificate:

Yes ___

No

___

Residence of Parents

or Legal Guardian

,

since

/

/

Street Address

City

Month

Day

Year

Residence (if Different from

Parent(s) or Legal Guardian

,

Street Address

City

Lived at this address since:

Name(s) and Relationship of Person(s) you live

with if other than parent(s) or legal guardian

/

/

Name

Month

Day

Year

Insurance Students participating in extracurricular activities, as defined by Pinellas County School Board Policy 4.10, must purchase the Mandatory School Accident Coverage for activities available by the School District. Football insurance is in force for football and all other activities. Mandatory School Accident Insurance provides coverage for all school related activities. Insurance may be purchased on-line.

Football Insurance		Mandatory School Accident Insurance
	Date Purchased		Date Purchased

EMERGENCY MEDICAL TREATMENT PERMISSION AND INFORMATION

I hereby authorize the school to obtain, through a physician of its own choice, any emergency care that may become reasonably necessary for the student listed on this form in the course of school sponsored athletics, activities and travel. Payment of all charges incurred for medical treatment is guaranteed by me or the insurance company providing primary coverage for the above named student.

* Please see attached FHSAA Pre-participation Physical Evaluation Form for pertinent medical conditions *

Student Participation Permission

***** PARTICIPATION IN COMPETITIVE ATHLETICS CAN RESULT IN SERIOUS INJURY, EVEN DEATH *****

I hereby give my consent for the above named student to represent his/her school in school sponsored athletics and activities. I understand the potential risks and that severe injury, including paralysis, or even death may occur. This permission includes team travel for local or out-of-town trips. Circle the sport(s) the student intends to play:

	Baseball	Cross Country	Football	Soccer	Swimming/Diving	Track	Volleyball	Wrestling
	Basketball	Cheerleading	Flag Football	Golf	Softball	Tennis

School attended last year:

Student’s Signature

/

Signature of Parent/GuardianHome/Work PhoneDateRelationship to the Student

/

Signature of Parent/Guardian	Home/Work Phone	Date	Relationship to the Student
If only one Parent/Guardian signature above, explain
reason:

AFFIDAVIT

STATE OF FLORIDA, COUNTY OF

I (SWEAR) (AFFIRM) that the above information is true and correct to the best of my knowledge.

X

(Signature of parent making affidavit)

Sworn to and subscribed before me this __________ day of ___________ A.D., ____________

(Signature of Notary Public, State of Florida)

(Print, type, or Stamp Commissioned Name of Notary Public) Personally Known  or Produced Identification * 

*Type of identification produced: My commission expires:

Notary Public Commission Number:

The FHSAA web site, www.fhsaa.org , and your school’s Athletic Director can best explain student eligibility requirements. If you have any questions about eligibility, please make an appointment with your schools’ Athletic Director before completing this form or trying out. Participation in extracurricular athletics and activities is a privilege and can be suspended or revoked by the school administration when deemed necessary.

List schools attended by above named student during:

9th grade: _____________________________________

10th grade: ____________________________________

11th grade: ____________________________________

12th grade: ____________________________________

If you have any questions regarding eligibility, meet with your school’s Athletic Director BEFORE trying out.