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2021-22 Sioux Valley Extra-Curricular Activities Information & Sign Off Form
Please complete the following form for each student athlete and push submit when finished. Thank you.
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Student-Athlete First Name
*
Your answer
Student-Athlete Last Name
*
Your answer
Student-Athlete Date of Birth
*
MM
/
DD
/
YYYY
Activities the Student-Athlete is participating in.
*
Your answer
Student-Athlete Grade
*
7th
8th
9th
10th
11th
12th
Emergency Contact Information (Mother) Name/Cell
*
Your answer
Emergency Contact Information (Father) Name/Cell
*
Your answer
Emergency Contact Information (Relative/Friend) Name/Cell
*
Your answer
List student-athlete allergies
*
Your answer
My son/daughter and parent has completed and/or viewed the following items/information. (If not, please contact Mr. Ruesink)
*
Athletic Physical (Please provide a copy to Mr. Ruesink if you have not already)
Impact Concussion Testing
Consent for release of medical information form & medical treatment
Risk Acknowlege & Consent to Participate
Proof of Insurance
Concussion Facts Sheet for Students
Concussion Facts Sheet for Parents
Sioux Valley Activities Code of Conduct
Academic Eligibility, Missing Practice/Competitions/Activity Ticket Sheet
Required
Signature- Please list the parent name completing this below. This will act as an electronic signature that you have completed and viewed all the necessary documents.
*
Your answer
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This form was created inside of State of South Dakota K-12 Data Center.
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