Student’s Name:
Date:
Dakota United CI Eligibility
This form only needs to be completed for students who are invited to play for the Varsity team.
This form only needs to be completed once during the course of a student’s participation as long
as the student participates in consecutive seasons. If your student plans or wishes to be
considered for the varsity team, please complete this form. There must be one form complete for
each student in a family that wishes to participate in the varsity program.
The Adapted Athletics: Cognitively Impaired Division is for students who are not able to
compete in traditional, able bodied athletics through their home schools due to their low
intellectual functioning. In order for a student to be able to participate at the varsity level, they
must meet certain eligibility requirements.
1. Students must be classified Cognitively Impaired by their school district. Cognitively
Impaired refers to students with significantly sub-average general intellectual functioning
resulting in or associated with concurrent deficits in adaptive behavior. Significantly subaverage intellectual functioning must be indicated by an intelligence quotient (IQ) below 70
on an intelligence test that is standardized, nationally normed, technically adequate, and
individually administered.
Does your student have documentation that they meet this requirement? __________
Please attach a copy of the page from your student’s 3-year assessment that shows an IQ
below 70. It may be called a “full scale” score as well. The most common tests used are
the WISC III and the Stanford Binet, though others are acceptable.
2. Players must have a current physical on file with their home schools. This must be updated
every 3 years. Please be certain this is done.
3. Players must be in grades 7-12. A student’s eligibility extends for 4 years from their entry
into 9th grade, and ends when their class graduates.
What grade is your student in? ___________
If your student is in 12th grade, how many years have they been in high school? __________
4. Players must be enrolled in a school district within Dakota County to play for Dakota United
Adapted Athletics.
What school does your child attend? _________________
What district? _______________
5. Players may not participate in an Adapted Program and an Able Bodied Interscholastic
Program in the same season.
Parent Signature:
Date: