Page 1 of 3 • CMS MS Athletic Participation Form • 5/31/13
Charlotte-Mecklenburg Schools
Middle School Student-Athlete Pre-Participation Form
TAB THROUGH FORM & TYPE INFORMATION
OR PRINT FORM AND WRITE INFORMATION
PERSONAL & EMERGENCY CONTACT INFORMATION
Student-Athlete’s Name (First, MI, Last): CMS Student ID #
Gender: M F Date of Birth: Age: Home Phone:
Resides At Street Address: City: State: Zip Code: County:
Father’s Name: Daytime Phone: Cell Phone:
Street Address: City: State: Zip Code: County:
Mother’s Name: Daytime Phone: Cell Phone:
Street Address: City: State: Zip Code: County:
If applicable… Guardian’s
Name:
Daytime Phone: Cell Phone:
Street Address: City: State: Zip Code: County:
• If student-athlete resides with other than parent(s), attach legal documentation of custody (guardianship or affidavit provided by Student Placement)
Failure to provide accurate and up-to-date residence information may be grounds for loss of athletic eligibility
SPORT (check all sports you are considering to participate in)
Fall Winter Spring
Cheerleading Basketball - Boy’s Baseball
Football Basketball - Girl's Soccer - Boy's
Golf - Boy's Cheerleading Soccer - Girl's
Golf - Girl's Track - Boy's
Softball Track - Girl's
Volleyball - Girl's
INSURANCE
School Board Policy JLA requires that all students who participate in athletics be adequately covered by medical or accident insurance.
We acknowledge that it is the signed responsibility to notify CMS of any changes that occur to the personal insurance policy below and affect the procedures in
which the above-named individual may receive treatment; this includes loss of coverage. We certify that we have purchased and will maintain in full force and effect
during student-athlete’s participation in athletics the following insurance policy:
Check One: School Accident Insurance Personal Insurance Company
Name of Insurance Company Policy Number Group Number
Insurance Phone for Authorization Policy Holder
RELEASE
In consideration of CMS allowing the above-named individual to participate in athletics, we agree to release and hold CMS, its athletic coaches, and other
employees free, harmless and indemnified from and against any and all claims, suits, or causes of action arising from or out of injury that the student-athlete may
suffer from participation in athletics other than an injury from gross or willful negligence.
ASSUMPTION OF RISK
We acknowledge and understand that there is a risk of injury involved in athletic participation. We understand that the student-athlete will be under the supervision
and the instructions of the coach in order to reduce the risk of injury to the student-athlete and other athletes. However, we acknowledge and understand that neither
the coach nor CMS can eliminate the risk of injury in sports. Injuries may and do occur. Sports injuries can be severe and in some cases may result in permanent
disability or even death. We freely, knowingly, and willfully accept and assume the risk of injury that might occur from participation in athletics.
HIPAA / FERPA RELEASE
The above named student-athlete has opted his/her rights under the US Department of Health and Human Resources guidelines. By signing this release, the
student-athlete allows sharing of medical information between the Sports Medicine Staff (team physicians and medical staff, athletic trainers, and student
assistants), the CMS Athletics Staff (Athletic Director and Coaches), CMS Administration and his/her medical provider(s). In the event of an emergency situation,
information may be shared with emergency medical personnel. Every reasonable effort will be made to protect this information. It is understood that once this
medical information is disclosed, it is no longer protected under the HIPAA/FERPA guidelines.
SEVENTH GRADE ENTRY
• This is my consecutive semester at Middle School
• I initially entered the seventh grade in the fall of (yr.)
• Last semester I attended School in City State
Parent/Guardian Initials: ______________ Student-Athlete Initials: ______________
We certify that all of the information provided by us on this form is correct. We agree by the rules of the NCDPI and CMS. We give our consent for the student-athlete
to receive a medical screening prior to participation in athletics and acknowledge that this is simply a screening evaluation and not suitable for regular health
care. If the student-athlete is injured while participating in athletics and CMS is unable to contact the parent, we grant CMS permission and the authority to obtain
necessary medical care and/or treatment for the student’s injury including first aid, CPR, medical or surgical treatment recommended by a physician and we accept
the financial responsibility for such medical care or treatment.
We (student and parents) certify that the home address shown in this document is the student’s sole bona fide residence, and we will notify the school principal
immediately of any change in residence, since such a move may alter the eligibility status of the student athlete.
All information contained in this form is accurate and correct.
Student-Athlete: Date:
(Signature)
Parent/Guardian: Date:
(Please Print Name)
Parent/Guardian: Date:
(Signature)
CERTIFICATION / MEDICAL AUTHORIZATION
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Instructions for Completing the NCHSAA Student-Athlete
Preparticipation Physical Evaluation (PPE)
In order to be medically eligible for participation in practice or in interscholastic athletic
contests, a student must have a completed NCHSAA PPE and submit it to the school. The
PPE is four (4) pages in length and includes the History Form, the Physical Examination
Form, and the Medical Eligibility Form.
The PPE History Form (pages 1-2) is completed and signed by the parent or legal
custodian on behalf of the student-athlete. The completed and signed PPE History Form
must then be presented to the examining Licensed Medical Professional (LMP)
(physician licensed to practice medicine (MD/DO), nurse practitioner or physician
assistant) for review when they fill out the Physical Examination Form.
The completed PPE Physical Examination Form (page 3) is signed and dated by the LMP
who performed the examination. The physical examination builds on information
obtained in the medical history.
The PPE Medical Eligibility Form (page 4), which is also signed and dated by the LMP,
indicates the student-athlete is either medically eligible or not medically eligible for
sports participation.
Student-Athlete COVID Questionnaire
Student-Athlete’s Name: __________________________________________________
Date of Birth: ____________________________ Age: __________________________
COVID RELATED QUESTIONS ABOUT THE STUDENT-ATHLETE
YES
NO
NA
1. Since January 1, 2020 have you been told that you have
had a positive test for COVID-19, OR have you been told by
a medical professional, your school, or local health
department that you have had to quarantine (stay home)
due to concern that you had COVID-19 symptoms?
2. If the answer to 1 was “Yes”, has the required Return to
Play Form: COVID-19 Infection Medical Clearance Releasing
The Student-Athlete to Resume Full Participation in
Athletics been completed?
3. Have you been fully vaccinated against COVID?
GENERAL QUESTIONS
(Explain “Yes” answers at the end of this form.
Circle questions if you don’t know the answer.) Yes No
1. Do you have any concerns that you would like to
discuss with your provider?
2. Has a provider ever denied or restricted your
participation in sports for any reason?
3. Do you have any ongoing medical issues or
recent illness?
HEART HEALTH QUESTIONS ABOUT YOU Yes No
4. Have you ever passed out or nearly passed out
during or after exercise?
5. Have you ever had discomfort, pain, tightness,
or pressure in your chest during exercise?
6. Does your heart ever race, utter in your chest,
or skip beats (irregular beats) during exercise?
7. Has a doctor ever told you that you have any
heart problems?
8. Has a doctor ever requested a test for your
heart? For example, electrocardiography (ECG)
or echocardiography.
■ PREPARTICIPATION PHYSICAL EVALUATION
HISTORY FORM
Note: Complete and sign this form (with your parents if younger than 18) before your appointment.
Name: ________________________________________________________________ Date of birth: _____________________________
Date of examination: _______________________________ Sport(s): _____________________________________________________
Sex: M/F __________________________________________
List past and current medical conditions. _____________________________________________________________________________
_______________________________________________________________________________________________________________
Have you ever had surgery? If yes, list all past surgical procedures. _______________________________________________________
_______________________________________________________________________________________________________________
Medicines and supplements: List all current prescriptions, over-the-counter medicines, and supplements (herbal and nutritional).
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Do you have any allergies? If yes, please list all your allergies (ie, medicines, pollens, food, stinging insects).
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Patient Health Questionnaire Version 4 (PHQ-4)
Over the last 2 weeks, how often have you been bothered by any of the following problems? (check box next to appropriate number)
Not at all Several days Over half the days Nearly every day
Feeling nervous, anxious, or on edge 0 1 2 3
Not being able to stop or control worrying 0 1 2 3
Little interest or pleasure in doing things 0 1 2 3
Feeling down, depressed, or hopeless 0 1 2 3
(A sum of ≥3 is considered positive on either subscale [questions 1 and 2, or questions 3 and 4] for screening purposes.)
HEART HEALTH QUESTIONS ABOUT YOU
(CONTINUED ) Yes No
9. Do you get light-headed or feel shorter of breath
than your friends during exercise?
10. Have you ever had a seizure?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No
11. Has any family member or relative died of heart
problems or had an unexpected or unexplained
sudden death before age 35 years (including
drowning or unexplained car crash)?
12. Does anyone in your family have a genetic heart
problem such as hypertrophic cardiomyopathy
(HCM), Marfan syndrome, arrhythmogenic right
ventricular cardiomyopathy (ARVC), long QT
syndrome (LQTS), short QT syndrome (SQTS),
Brugada syndrome, or catecholaminergic poly-
morphic ventricular tachycardia (CPVT)?
13. Has anyone in your family had a pacemaker or
an implanted debrillator before age 35?
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BONE AND JOINT QUESTIONS Yes No
14. Have you ever had a stress fracture or an injury
to a bone, muscle, ligament, joint, or tendon that
caused you to miss a practice or game?
15. Do you have a bone, muscle, ligament, or joint
injury that bothers you?
MEDICAL QUESTIONS Yes No
16. Do you cough, wheeze, or have difculty
breathing during or after exercise?
17. Are you missing a kidney, an eye, a testicle
(males), your spleen, or any other organ?
18. Do you have groin or testicle pain or a painful
bulge or hernia in the groin area?
19. Do you have any recurring skin rashes or
rashes that come and go, including herpes or
methicillin-resistant Staphylococcus aureus
(MRSA)?
20. Have you had a concussion or head injury that
caused confusion, a prolonged headache, or
memory problems?
21. Have you ever had numbness, had tingling, had
weakness in your arms or legs, or been unable
to move your arms or legs after being hit or
falling?
22. Have you ever become ill while exercising in the
heat?
23. Do you or does someone in your family have
sickle cell trait or disease?
24. Have you ever had or do you have any prob-
lems with your eyes or vision?
MEDICAL QUESTIONS (CONTINUED ) Yes No
25. Do you worry about your weight?
26. Are you trying to or has anyone recommended
that you gain or lose weight?
27. Are you on a special diet or do you avoid
certain types of foods or food groups?
28. Have you ever had an eating disorder?
FEMALES ONLY Yes No
29. Have you ever had a menstrual period?
30. How old were you when you had your rst
menstrual period?
31. When was your most recent menstrual period?
32. How many periods have you had in the past 12
months?
Explain “Yes” answers here.
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete
and correct.
Signature of athlete: ______________________________________________________________________________________________________
Signature of parent or guardian: __________________________________________________________________________________________
Date: ________________________________________________________
© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine,
American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educa-
tional purposes with acknowledgment.
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■ PREPARTICIPATION PHYSICAL EVALUATION
PHYSICAL EXAMINATION FORM
Name: _________________________________________________________________ Date of birth: ____________________________
PHYSICIAN REMINDERS
1. Consider additional questions on more-sensitive issues.
• Do you feel stressed out or under a lot of pressure?
• Do you ever feel sad, hopeless, depressed, or anxious?
• Do you feel safe at your home or residence?
• Have you ever tried cigarettes, e-cigarettes, chewing tobacco, snuff, or dip?
• During the past 30 days, did you use chewing tobacco, snuff, or dip?
• Do you drink alcohol or use any other drugs?
• Have you ever taken anabolic steroids or used any other performance-enhancing supplement?
• Have you ever taken any supplements to help you gain or lose weight or improve your performance?
• Do you wear a seat belt, use a helmet, and use condoms?
2. Consider reviewing questions on cardiovascular symptoms (Q4–Q13 of History Form).
EXAMINATION
Height: Weight:
BP: / ( / ) Pulse: Vision: R 20/ L 20/ Corrected: □ Y □ N
MEDICAL NORMAL ABNORMAL FINDINGS
Appearance
• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, hyperlaxity,
myopia, mitral valve prolapse [MVP], and aortic insufciency)
Eyes, ears, nose, and throat
• Pupils equal
• Hearing
Lymph nodes
Heart
a
• Murmurs (auscultation standing, auscultation supine, and ± Valsalva maneuver)
Lungs
Abdomen
Skin
• Herpes simplex virus (HSV), lesions suggestive of methicillin-resistant Staphylococcus aureus (MRSA), or
tinea corporis
Neurological
MUSCULOSKELETAL NORMAL ABNORMAL FINDINGS
Neck
Back
Shoulder and arm
Elbow and forearm
Wrist, hand, and ngers
Hip and thigh
Knee
Leg and ankle
Foot and toes
Functional
• Double-leg squat test, single-leg squat test, and box drop or step drop test
a
Consider electrocardiography (ECG), echocardiography, referral to a cardiologist for abnormal cardiac history or examination ndings, or a combi-
nation of those.
Name of health care professional (print or type): ___________________________________________________ Date: ___________________
Address: ________________________________________________________________________ Phone: ___________________________
Signature of health care professional: _____________________________________________________________________, MD, DO, NP, or PA
© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine,
American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educa-
tional purposes with acknowledgment.
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Approved for Use Beginning March 2021
■ PREPARTICIPATION PHYSICAL EVALUATION
MEDICAL ELIGIBILITY FORM
Name: _______________________________________________________ Date of birth: _________________________
□ Medically eligible for all sports without restriction
□ Medically eligible for all sports without restriction with recommendations for further evaluation or treatment of
__________________________________________________________________________________________________
__________________________________________________________________________________________________
□ Medically eligible for certain sports
__________________________________________________________________________________________________
__________________________________________________________________________________________________
□ Not medically eligible pending further evaluation
□ Not medically eligible for any sports
Recommendations: ___________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
I have examined the student named on this form and completed the preparticipation physical evaluation. The athlete does not have
apparent clinical contraindications to practice and can participate in the sport(s) as outlined on this form. A copy of the physical
examination ndings are on record in my ofce and can be made available to the school at the request of the parents. If conditions
arise after the athlete has been cleared for participation, the physician may rescind the medical eligibility until the problem is resolved
and the potential consequences are completely explained to the athlete (and parents or guardians).
Name of health care professional (print or type): __________________________________________ Date: ____________________________
Address: _________________________________________________________________________ Phone: ___________________________
Signature of health care professional: _____________________________________________________________________, MD, DO, NP, or PA
SHARED EMERGENCY INFORMATION
Allergies: ____________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Medications: ________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Other information: ____________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Emergency contacts: ___________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine,
American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educa-
tional purposes with acknowledgment.
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Approved for Use Beginning March 2021
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What is a concussion? A concussion is an injury to the brain caused by a direct or indirect blow to the
head. It results in your brain not working as it should. It may or may not cause you to black out or pass
out. It can happen to you from a fall, a hit to the head, or a hit to the body that causes your head and
your brain to move quickly back and forth.
How do I know if I have a concussion? There are many signs and symptoms that you may have
following a concussion. A concussion can affect your thinking, the way your body feels, your mood, or
your sleep. Here is what to look for:
Thinking/Remembering
Physical
Emotional/Mood
Sleep
Difficulty thinking clearly
Taking longer to figure things out
Difficulty concentrating
Difficulty remembering new information
Headache
Fuzzy or blurry vision
Feeling sick to your stomach/queasy
Vomiting/throwing up
Dizziness
Balance problems
Sensitivity to noise or light
Irritability-things bother you
more easily
Sadness
Being more moody
Feeling nervous or worried
Crying more
Sleeping more than usual
Sleeping less than usual
Trouble falling asleep
Feeling tired
Table is adapted from the Centers for Disease Control and Prevention (http://www.cdc.gov/concussion/)
What should I do if I think I have a concussion? If you are having any of the signs or symptoms listed
above, you should tell your parents, coach, athletic trainer or school nurse so they can get you the help
you need. If a parent notices these symptoms, they should inform the school nurse or athletic trainer.
When should I be particularly concerned? If you have a headache that gets worse over time, you are
unable to control your body, you throw up repeatedly or feel more and more sick to your stomach, or
your words are coming out funny/slurred, you should let an adult like your parent or coach or teacher
know right away, so they can get you the help you need before things get any worse.
What are some of the problems that may affect me after a concussion? You may have trouble in
some of your classes at school or even with activities at home. If you continue to play or return to play
too early with a concussion, you may have long term trouble remembering things or paying attention,
headaches may last a long time, or personality changes can occur Once you have a concussion, you are
more likely to have another concussion.
How do I know when it’s ok to return to physical activity and my sport after a concussion? After
telling your coach, your parents, and any medical personnel around that you think you have a concussion,
you will probably be seen by a doctor trained in helping people with concussions. Your school and your
parents can help you decide who is best to treat you and help to make the decision on when you should
return to activity/play or practice. Your school will have a policy in place for
how to treat concussions.
You should not return to play or practice on the same day as your suspected concussion.
This information is provided to you by the UNC Matthew Gfeller Sport-Related TBI Research Center, North Carolina Medical Society, North
Carolina Athletic Trainers’ Association, Brain Injury Association of North Carolina, North Carolina Neuropsychological Society, and North
Carolina High School Athletic Association.
Gfeller-Waller NCHSAA Student-Athlete & Parent/Legal Custodian
Concussion Information Sheet
You should not have any symptoms at rest or during/after activity when you return to play, as this is
a sign your brain has not recovered from the injury.
Revised: February 2021 - Approved for use in current or upcoming school year.
Gfeller-Waller NCHSAA Student-Athlete & Parent/Legal Custodian
Concussion Statement Form
Instructions: The student athlete and his/her parent or legal custodian, must initial beside each statement
acknowledging that they have read and understand the corresponding statement. The student-athlete
should initial in the left
column and the parent or legal custodian should initial in the right column. Some
statements are applicable only to the student-athlete and should only be initialed by the student-athlete.
This form must be completed for each student-athlete, even if there are multiple student-athletes in the
household.
Student-Athlete Name: (please print)
Parent/Legal Custodian Name(s): (please print)
Student-
Athlete
Initials
Parent/Legal
Custodian(s)
Initials
A concussion is a brain injury, which should be reported to my parent(s) or legal
custodian(s), my or my child’s coach(es), or a medical professional if one is
available.
A concussion cannot be “seen.” Some signs and symptoms might be present
immediately; however, other symptoms can appear hours or days after an injury.
I will tell my parents, my coach and/or a medical professional about my injuries and
illnesses.
Not
Applicable
If I think a teammate has a concussion, I should tell my coach(es), parent(s)/ legal
custodian(s) or medical professional about the concussion.
Not
Applicable
I, or my child, will not return to play in a game or practice if a hit to my, or my child’s,
head or body causes any concussion-related symptoms.
I, or my child, will need written permission from a medical professional trained in
concussion management to return to play or practice after a concussion.
Based on the latest data, most concussions take days or weeks to get better. A
concussion may not go away, right away. I realize that resolution from a concussion
is a process that may require more than one medical visit.
I realize that ER/Urgent Care physicians will not provide clearance to return to play
or practice, if seen immediately or shortly after the injury.
After a concussion, the brain needs time to heal. I understand that I or my child is
much more likely to have another concussion or more serious brain injury if return to
play or practice occurs before concussion symptoms go away.
Sometimes, repeat concussions can cause serious and long-lasting problems.
I have read the concussion symptoms listed on the Student-Athlete/ Parent Legal
Custodian Concussion Information Sheet.
I have asked an adult and/or medical professional to explain any information
contained in the Student-Athlete & Parent Concussion Statement Form or
Information Sheet that I do not understand.
By signing below, we agree that we have read and understand the information contained in the Student-
Athlete & Parent/Legal Custodian Concussion Statement Form, and have initialed appropriately beside
each statement
.
Signature of Student-Athlete Date
Signature of Parent/Legal Custodian
Date
Revised: February 2021 - Approved for use in current or upcoming school year.
Charlotte-Mecklenburg Schools
Interscholastic Athletics
Student-Parent Honor Code
Revised 5/14/14
This Honor Code must be initialed and signed before a student may dress and/or compete in an athletic contest.
STUDENT’S NAME (print):
SCHOOL (print):
SPORT: .
GRADE: .
PARENT / LEGAL CUSTODIAN / LEGAL GUARDIAN / HARDSHIP CAREGIVER NAME (print):
STUDENT’S DOMICILE (print):
Number & Street
City/Town, State
Zip Code
I understand the eligibility requirements for the student named on the Honor Code to take part in interscholastic athletics in Charlotte-
Mecklenburg Schools. If I had questions, the school athletic director answered them prior to my initialing/signing the Honor Code.
My initials and signature acknowledge that:
Student-Athlete
Initials
Parent,
Legal Custodian,
Legal Guardian or
Hardship Caregiver
Initials
N/A
I am the parent, legal custodian or legal guardian of the student named above or I have been
designated as the Hardship Caregiver by the CMS Student Placement Office.
ALL information I am providing on this Honor Code is the truth. My correct and current address is
provided above. I understand that lying is cheating.
The address listed on this form, and provided to the school registrar & school athletic director
where the student is enrolled, is where I actually live at the present time.
I currently live in the attendance area for the school listed on this Honor Code, or the student was
assigned to the school listed on the Honor Code through the student assignment lottery, or the
student received a transfer to the school.
I am not aware of any other students or parents who have given false information to CMS so they
can participate on an athletic team.
I will immediately report all suspected athletic eligibility violations to the principal or athletic
director at the school listed on this honor code.
I am aware that if I provide false information concerning athletic eligibility to the school and/or do
not report information about known athletic eligibility falsifications of others that I may be
penalized by the North Carolina High School Athletic Association (high school only) and by
Charlotte-Mecklenburg Schools. I may lose the privilege of participation in athletics for 365 days
and my team may have to forfeit contests.
N/A
N/A
I am aware that if I provide false information concerning athletic eligibility; do not report
information about known athletic eligibility falsifications of others; and/or do not update my home
address with the school registrar and athletic director the student-athlete listed above and his or
her athletic team may be penalized by the North Carolina High School Athletic Association (high
school only) and by Charlotte-Mecklenburg Schools, including losing the privilege of participation
in athletics for 365 days and the team may have to forfeit contests.
Signature of Student Listed Above
Date
Signature of Parent, Legal Custodian, Legal Guardian or Hardship Caregiver Listed Above
Date
MIDDLE SCHOOL FOOTBALL ONLY GREEN FORM
NOTICE AND RELEASE
IMPORTANT: THIS NOTICE AND RELEASE MUST BE SIGNED AND
RETURNED BEFORE YOUR STUDENT-ATHLETE CAN
PARTICIPATE IN THE MIDDLE SCHOOL FOOTBALL
PROGRAM.
To: Parents of students interested in participating in the Middle School
Football Program
Subject: Student Accident Insurance – Middle School Football
Please read this Notice and Release carefully and make sure that you understand
its provisions before deciding whether to permit your student-athlete to
participate in the Middle School Football Program.
1. The Charlotte-Mecklenburg School System provides accident insurance in the
amount of $25,000 at no charge for all students participating in the Middle School
Football Program. The Middle School Football accident insurance benefits
provided by the school system will pay only toward those covered
expenses in excess of expenses recoverable from other insurance. This
means that any applicable personal insurance that you may carry would apply
first, and the Middle School Football Accident Insurance would apply only to
those covered expenses not paid by your other insurance. If you do not have
other insurance, the Middle School Football Accident Insurance will pay toward
covered expenses up to $25,000.
2. There are limitations under the Middle School Football Accident Insurance
coverage. It will not always pay all of the charges incurred for every
accident. This insurance only provides certain benefits for injury or loss due to
practicing and playing in the Middle School Football program. For a summary of
the coverage benefits, please refer to the Student Accident Insurance Information
(for Middle School Football) that has been furnished to each student interested in
participating in the Middle School Football Program. If you did not receive the
information or if you have questions about the insurance coverage provided to
participants in the Middle School Football Program, contact the Athletic
Director/Coach where your student-athlete is enrolled.
3. Every player is required by the National Federation of State High School Athletic
Associations (NFSHSAA) regulations to wear a mouth guard. An additional
$150.00 per sound natural tooth is available for any player who sustains injuries
to their teeth as a result of the failure of the mouth guard, provided that they were
wearing the required mouth guard at the time of the injury.
PLEASE COMPLETE THE BACK OF THE FORM
2021
MIDDLE SCHOOL FOOTBALL ONLY GREEN FORM
4. To be eligible for practice or participation in the Middle School Football Program,
each participant must receive an ANNUAL MEDICAL EXAMINATION and return
a physical examination form each calendar year (every 395 days) signed by a
physician licensed to practice medicine.
5. Neither the Board of Education nor any of its employees assumes any
responsibility for claims resulting from injury to your Student Athlete while they
are participating in the Middle School Football Program. This means that you will
have to pay for any medical expenses not covered by the Middle School Football
Accident Insurance, any personal insurance coverage that you might have and/or
any other applicable insurance.
I, , (print name) hereby state that I
have read and understand the provisions of this Notice and Release as well as the
Student Accident Insurance information for the Middle School Football Accident
Insurance coverage. I also state that prior to signing this document, I have had an
opportunity to ask questions and that my questions have been answered to my
satisfaction. I acknowledge that neither the Board of Education nor any of its
employees assumes any responsibility for claims resulting from injury to my Student-
Athlete while they are participating in the Middle School Football Program. In
consideration of my Student-Athlete being permitted to participate in the Middle School
Football Program, I hereby waive, release, and forever discharge the Charlotte-
Mecklenburg Board of Education and its employees from any responsibility for claims
resulting from injuries to my Student-Athlete due to their participation in the Middle
School Football Program. I also state that my Student-Athlete has received a Medical
Examination and has returned a physical examination form in compliance with the policy
set forth in paragraph 4 of this Notice and Release. I certify that I consent to have my
Student-Athlete participate in the Middle School Football Program offered at their
school.
SIGNED: (Parent or Legal Guardian) Date
Address:
Student’s Full Name:
School:
2021
ALL SPORTS EXCEPT FOOTBALL BLUE FORM
NOTICE AND RELEASE
IMPORTANT: THIS NOTICE AND RELEASE MUST BE SIGNED AND
RETURNED BEFORE YOUR SON/DAUGHTER CAN
PARTICIPATE IN THIS PROGRAM.
TO: Parents of students interested in participating in Athletics
SUBJECT: Student Accident Insurance for Athletics
SPORT (S): _____________________________________________________
Please read this Notice and Release carefully and make sure that you understand
its provisions before deciding whether to permit your son or daughter to
participate in middle or senior high athletics.
1. Board of Education policy requires that the Student Accident Insurance offered
by the school system, will be required for all students participating in middle and
senior high school athletics unless an insurance waiver form is signed by the
parent indicating adequate personal insurance and releasing the Board of
Education and its employees from responsibility for any claim due to injuries
received while participating in a school sponsored athletic program.
2. There are limitations in the Student Accident Insurance coverage. IT WILL NOT
ALWAYS PAY ALL OF THE CHARGES INCURRED FOR EVERY ACCIDENT.
For a summary of the coverage and benefits provided by the Student Accident
Insurance, please read the current Student Accident Insurance Brochure that
was furnished to each student at the beginning of the school year. If you did not
receive the brochure or if you have questions about the insurance coverage
provided under the policy, contact the Athletic Director at the school where your
son/daughter is enrolled.
3. To be eligible for practice or participation in any school athletic program, each
participant must receive an ANNUAL MEDICAL EXAMINATION and return a
physical examination form each calendar year (every 395 days) signed by a
physician licensed to practice medicine.
4. Neither the Board of Education nor any of its employees assumes any
responsibility for claims resulting from injury to your son/daughter while he or she
is participating in the school athletic program. This means that you will have to
pay for any medical expenses not covered by the Student Accident Insurance,
any personal insurance coverage that you might have and/or any other
applicable insurance.
2021
PLEASE COMPLETE THE BACK OF THE FORM
ALL SPORTS EXCEPT FOOTBALL BLUE FORM
I, ___________________________________________, (print name) hereby state that I
have read and understand the provisions of this Notice and Release as well as the
Student Accident Insurance Brochure. I further state that prior to signing this document,
I have had an opportunity to ask questions and that my questions have been answered
to my satisfaction. I acknowledge that neither the Board of Education nor any of its
employees assumes any responsibility for claims resulting from injury to my
son/daughter while he or she is participating in the school athletic program. I HEREBY
WAIVE, RELEASE, AND DISCHARGE the Charlotte-Mecklenburg Board of Education
and its employees from any responsibility for claims resulting from injuries to my
son/daughter due to his or her participation in this athletic program. I hereby certify that
my son/daughter has received a MEDICAL EXAMINATION and has returned a physical
examination form in compliance with the policy set forth in paragraph 3 of this Notice
and Release. I certify that I consent to have my son/daughter participate in school
athletic activity as identified on this Notice and Release. I make the following
representation and selection (check one, sign and return promptly):
__________ I have adequate personal insurance that will cover injuries that might be
sustained by my son/daughter as a result of his/her participation in the
school athletics. I understand that in the event my son/daughter sustains
any injuries as a result of his/her participation in school athletics, I am
responsible for payment of medical expenses or other items not covered
by any personal insurance.
__________ My son/daughter has enrolled in the Student Accident Insurance Program
on _____/_____/_____, and I understand that in the event my
son/daughter sustains any injuries as a result of his/her participation in
school athletics, I am responsible for payment of any medical expenses or
other items not covered by the Student Accident Insurance.
SIGNED: (Parent or Legal Guardian) Date
ADDRESS:
STUDENT’S FULL NAME:
SCHOOL:
2021
Charlotte‐MecklenburgSchools
ApplicationforWaiverofAthleticParticipationFee
InJune2010,theBoardofEducationapprovedparticipationfeesformiddleandhighschoolathletic
teams.Middleschoolstudentspayafeeof$75.00andhighschoolstudentspayafeeof$125.00for
eachinterscholasticsportsseasoninwhichtheyparticipateononeormoreteams.Paymentofthisfe
e
isrequir
edbyadeadlinewhichisestablishedforeachsportsseason.
InJune2014,theBoardofEducationapp
rovedCMStoparticipateinthefederalCommunity
EligibilityProvision(CEP).TheCEPeliminatestheneedforadistricttoqualifystudentsforfreeand
reducedpricemealsandtrackwhichstudentsareparticipating.Studentsareidentifiedasdirectly
certified(throughdatamatching)forfr
eemealsbecausetheyliveinhouseholdsthatpart
icipatein
SupplementalNutritionAssistanceProgram(SNAP),TemporaryAssistanceforNeedyFamilies
(TNAF),orFoodDistributionProgramonIndianReservations(FDPIR),aswellaschildrenwhoare
qualifiedforfreeschoolsmealswithoutsubmittingaschoolmealapplicationbecauseoftheirstatusas
beinginfo
stercare
,enrolledinHeadStart,homeless,runaway,ormigrantstudents.
Studentsidentified
asdirectlycertifiedareeligibletohavetheirparticipationfeewaived.Noother
studentsareeligibleforthisfeewaiver.Eachapplicant’sdirectlycertifiedstatusiscurrentandmust
beverifiedbyChildNutritionServices.Eachapplicant’swaiverformmustbeaccompaniedbya
currentcopyoftheCMSChildNutritionmealeligibilityletterorabenefitsletterfromDSSbeforethe
athleticparticipationfeecanbewaived.
Ifyouwishtoapplyforafeewaiver,pleasefillouttheinformationbelowandreturnthisformto
yourchild’sathleticdirectororathleticcoach.Partiallycompletedformswillnotbeaccepted.
Aseparateformmustbefilledoutforeachstudent‐athleteforwhomawaiverisrequested.
Nameofstudent _________________________________________________[pleaseprint]
StudentIDnumber _________________________________________________[pleaseprint]
School _________________________________________________
[pleaseprint]
Parent/guardianname
Address
_______________________________
__________________[pleaseprint]
________________________________ ________________[pleaseprint]
Number/Street
City,State,Zip
IherebyapplyforawaiveroftheCMSathleticparticipationfeeandaffirmthe
informationprovidedonandwiththisapplicationisaccurate.I understand my
Athletic Director is authorized to view the waiver information.
______________________________________________________
Parent/Guardian(PrintName)
______________________________________________________ ___________________________
Parent/guardiansignatureDate
May 2020
Student-Athlete & Parent/Guardian
Confirmation of Signed Athletic Eligibility Forms
My signature below confirms I read, understand and completed in full the on-line athletic eligibility
forms noted below. In addition, I emailed the documents ________________________________
(file name)
to ______________________________ on ______________________.
(school athletic director) (date)
My signature also confirms the information I provided on all athletic eligibility forms is accurate and
truthful. I understand false and/or
inaccurate information may result in a 365-day athletic ineligibility
period for the student-athlete who signs below. I understand that an electronic signature has the
same legal effect and can be enforced in the same way as a written signature and by typing
my name in the packet; I am electronically signing those documents.
Student-Athlete Signature ___________________________________ Date _____________
Print Name ___________________________________
Parent/Guardian Signature ___________________________________ Date _____________
Print Name ___________________________________
Athletic Forms
Package
(Initial all forms submitted or printed)
____ CMS Middle School Student-Athlete Pre-Participation Form
____ NCHSAA MS Pre-Participation Physical Evaluation
____ NCHSAA MS Pre-Participation Physical Evaluation (Spanish)!
____ Concussion Statement Form Student/Parent
____ Athletic Honor Code Form Student/Parent
____ 2021-2 Football Insurance-Green Form
____ 2021-2 All Other Sports Insurance-Blue Form
____ Athletic Participation Fee Waiver Application (if Applicable)
(Print & complete this form and hand deliver to AD)
____ Confirmation of Signed Eligibility Forms
(Print & complete this form and hand deliver to AD)
5-4-21
