MIDDLE SCHOOL ACTIVITY FORMS
Participants in Middle School Athletics/Activities must complete and return these forms to the Activities
Office at Fridley High or to Mr. Powell at Fridley Middle School prior to participation in even one practice.
The following is a checklist to guide you in the process.
Athletic/Activity Registration form
Emergency Contact Information Card
The appropriate fee has been paid using the ESTORE (preferred). www.fridley.k12.mn.us. The
ESTORE tab is located under the Parent/Student Info Tab or the fee is attached.
ELECTRONIC CHECK CONVERSION NOTICE:
When you provide a check as payment, you authorize us either to use information from your check to makes a one-time electronic fund
transfer from your account or to process the payment as a check transaction. When we use information from your check to make an
electronic fund transfer, funds may be withdrawn from your account as soon as the same day you make your payment. For inquiries
please call 763-502-5018
My student qualifies for the Federal Free/Reduced lunch program. I have paid the $15.00 minimum
fee using the ESTORE. (Preferred) or I have attached the $15.00 Minimum Fee. We are aware that
there are circumstances where families may need to make arrangements for payment. Please contact
Dan Roff at 763-502-5605 or Sue Hanson at 763-502-5606 to discuss payment options.
A current physical is on file in the athletic office.(physicals are valid for 3 years)
Middle School Extracurricular Eligibility Policy
Complete the MSHSL Eligibility Statement and Annual Health Questionnaire only if you are
registering for one of the following 7-12 sports.
Boys and Girls Cross Country
Boys and Girls Swimming & Diving
Girls Tennis
Dance Team
Gymnastics
Boys and Girls Golf
Girls Softball (Only if you register to play on the JV or Varsity
Speech
If you have questions, please call Sue in the High School Activities Office at 763-5025606, or Jay Powell at FSM – 763-502-5504.
ACTIVITY REGISTRATION AND ASSUMED RISK AGREEMENT
Name of Student
Grade
FEES: Refer to the chart below. ISD #14 prefers that you pay your fee online using the E-Store. You can use
your bankcard or your credit card. www.fridley.k12.mn.us and follow the link to our EStore under Parent
/Student Info. You may also email the completed forms to: sue.hanson@fridley.k12.mn.us. Forms can also be
turned in to Ms. Lori Jacob at Fridley Middle School
All paperwork must be complete and proof of a current physical is required for ANY sport.
Fall Sports
Cross Country (7-12)
Dance Line (7-12)
Football (8 only)
Girls Swimming (7-12)
Girls Tennis (7-12)
Soccer (7 & 8)
Volleyball (7 & 8)
Fee
$140
$50
$95
$140
$140
$85
$85
Winter Sports
Boys Basketball (8 )
Boys Swimming(7-12)
Dance Team(7-12)
Girls Basketball (8 )
Gymnastics(7-12)
Wrestling (6,7,8)
Fee
$85
$140
$140
$85
$140
$85
Spring Sports
Fee
Baseball(7 & 8)
Boys Tennis (7 & 8)
Golf (7-12)
Softball (7-12)
Softball (7 & 8 only)
Track (7 & 8)
$85
$85
$140
$140
85.00
$85
MS FINE ARTS FEE
5th & 6th Grade Play
7th & 8th Grade Play
Speech(7-12)
$25
$25
$85
* NOTE - All students participating in an activity at the MS must pay a $15 minimum fee. If a student qualifies for
Free or reduced lunch under the guidelines of the Federal Free Lunch program the participation fee for any activity
will be $15.00. We are also aware that there are circumstances where families may need to make arrangements for
payments. Please contact Dan Roff at 763-502-5605 or Sue Hanson at 763-502-5606 to make financial arrangements.
I understand that participation of any nature in an activity offered by District #14 can be dangerous and involves the RISK
of potential serious injury. I understand these risks, especially those involving contact sports, could involve death, serious
head, neck, or spinal injuries which may result in partial or complete paralysis. In addition, injuries may occur which
affect all or any part of the skeletal, muscular, visual, and circulatory systems or may impair my general well being. Such
injury could seriously affect my future ability to earn a living or to live a full and productive life.
I understand and am willing to accept responsibility for following all rules established by the coaches regarding behavior,
playing skills, and training regulations etc.
I have read and fully understand the risk potential indicated above.
Signature of Parent or Guardian
Signature of Student
Date
INSURANCE WAIVER
It is important you read this letter as it explains the District's position on athletic insurance. The District does not provide any type of health or
accident insurance for injuries incurred by your child at school. We encourage families to have accident coverage on their children, prior to
participation in any sports or school sponsored activity. Athletic insurance is available for those interested. Premiums range between
$9.00 and $215.00 depending upon the plan that you choose. Premium Envelope and/or more information about this coverage
is available from Sue in the Athletic Office at the High School. Please complete the following and return to the Athletic Office:
I DESIRE COVERAGE AND I AM RETURNING THE ENVELOPE WITH THE CORRECT PREMIUM
ENCLOSED.
I DO NOT DESIRE INSURANCE COVERAGE. I/WE feel that our insurance protection is adequate.
Signature of Parent or Guardian
Signature of Student
Phone Number
EMERGENCY MEDICAL INFORMATION
Sport or Activity you are registering for:
All participants in Athletics or Fine Arts activities must complete this form for EVERY Sport or Fine Arts Activity that you
participate and return it with your registration information. Sue Hanson will stamp it and it will become your clearance to
participate in the sport or activity that you are registering for. NO EXCEPTIONS. The coach will keep this form with him/her
and will be able to give it to medical personnel if treatment for an injury is necessary. Please notify us immediately if there
are changes in a student’s emergency information.
If you have a question about this process - please call – Sue Hanson 763-502-5606.
STUDENT NAME:
GRADE:
Known Allergies/Medical Conditions:
Parent/Guardian
Work:
Home:
Parent/Guardian
Work:
Home:
Emergency Contact: (Other than Parent-parent will be contacted first)
1. Name:
Relationship:
Phone:
2. Name:
Relationship:
Phone:
I have verified that all emergency information for my child is correct and give active permission to share health concerns with the
appropriate staff for my child’s safety. My signature authorizes the school to contact the doctor/clinic and/or provide emergency
vehicle transportation to the designated hospital in the event that I cannot be reached.
Date:
Signed:
Relationship to child:
Fridley Middle School Extracurricular Eligibility Policy
The purpose of eligibility requirements for participation in extracurricular activities is one of ensuring the academic well being of
the individual student. Such a policy should reflect the intention of placing a top priority on the academic purpose of the middle
school.
Extracurricular Academic Policy
1.
2.
3.
2.
2.
4.
5.
Students are expected to be in good academic standing.
Any student failing (1) or more classes will be ineligible to attend or participate in any extracurricular contest until the
grade has been restored to a “passing” status.
Eligibility is restored after the passing grades have been verified by the teachers and coach.Extracurricular Attendance
Policy
Students must be at school a minimum of 3 class periods to be eligible to participate in extracurricular activities that day.
Student assigned restitution resulting from 5 or more tardies to class, will immediately become ineligible to participate.
Eligibility will only be restored after all restitution has been completed.
A student that is truant from a class will not participate or attend the extracurricular activity for that day.
Attendance or participation in an extracurricular activity on the day a student has lost eligibility will result in the
immediate removal from that team for the season.
Extracurricular Discipline Policy
1.
2.
3.
4.
A formal referral to the assistant principal that results in reprimand or one period of school reassignment, or the
acquisition of a (1) detention will result in a coach-imposed penalty. (e.g. running or laps). The acquisition of an
administrative second (2) detention during the season will result in no extracurricular activities or attendance to an
extracurricular activity during the days that the detentions are assigned. A third (3) detention, along with the loss of
practice attendance, will result in a one-contest suspension and no attendance to that contest. Detentions beyond three
will result in additional contest suspensions and eventual removal from the team.
Assignment of 1-3 days of in-school suspension (ISS) will result in a one–contest suspension. A student may continue to
practice .Assignment of a 4th day will result in a second contest suspension, suspension from practice for the assigned
days and a possible removal from the team.
A student may not participate in any activity or be present at any school related function during an out-of-school
suspension. A 2nd out of school suspension may result in a removal from all extra curricular activities for the year.
Attendance or participation in an extracurricular activity on the day a student has lost eligibility will result in the
immediate removal from that team for the season.
General Extracurricular Policies
1.
Pre-Season Paperwork-All paperwork must be complete before the student is allowed to participate in an activity or sport.
A clearance card will be issued from Sue Hanson in the district activity office indicating the student is cleared for
participation. No student can participate in any extracurricular activities until Sue Hanson clears them for participation.
2. Athletic Committee- This committee is composed of members of the coaching staff, a building administrator, and the
middle school activities director. The purpose of this committee is to review and refine current practice, policies, and
procedures of the entire middle school athletics program to ensure that they reflect the philosophy of the middle school
administration.
3. Physicals- No student is eligible for participation until a valid physical is on file.
4. Equipment- All issued equipment must be returned or paid for before the student can participate in another extracurricular
activity. Coaches must turn-in an official roster and equipment check-out list before the first game.
5. Scholarship- Students who qualify for the Federal Free or Reduced Lunch Program can apply for a fee waiver. Students
with Financial Hardship may also apply.
6. Co-Ed Bus Transportation- Students of opposite genders are expected to be seated in different sections of the bus.
Females are to sit in the front portion of the bus, males in the back (or visa versa).
7. Cutting- it is at the coach’s discretion to cut students from a team or activity. Cutting will take place when it is in the best
interest of the team to reduce numbers.
8. Roster Additions- The roster for a team or activity must be finalized after 8 official contact days. After 8 contact days, no
new members may be added to the roster. Teams low in numbers will be excluded from the 8 contact day policy.
9. Spiked Shoes- Spiked shoes can only be worn on the athletic fields. Athletes are to refrain from wearing them in the
building, bus, gym, etc.
10. Practice- Students who have late afternoon practice are not to remain in the building before or after practice unless under
the direct supervision of a coach.
11.
By signing below, I accept the terms of the Fridley Middle School Extracurricular Eligibility Policies.
Guardian Signature:
Student Signature:
>>COMPLETE THESE 2 PAGES ONLY IF YOU ARE PARTICIPATING IN ONE OF THE 7-12 SPORT LISTED ON PAGE ONE<<
2013-2014 MSHSL ELIGIBILITY STATEMENT
Statement to be signed by the participant from a MSHSL member school and by the participant’s parent or guardian
Please check all items:
I have read, understand, and acknowledge receiving the 2013-2014 MSHSL Eligibility Brochure, which contains only a summary of the
eligibility rules of the Minnesota State High School League. I understand that a copy of the Official Handbook of the MSHSL is on file
with the senior high school athletic director and or principal and that I may review it, in its entirety, if I so choose. The Official Handbook
and MSHSL bylaws are also posted on the MSHSL website: www.MSHSL.org under Handbook.
We, the student and parent, have reviewed Concussion Management Recommendations for MSHSL Athletes contained in the
Eligibility Brochure and on the following website: www.cdc.gov/concussion.
I understand that once I sign the eligibility statement all eligibility rules apply:



Twelve (12) months of the year;
Whether I am currently participating or not;
Continuously from the first signing of the statement through the completion of my high school eligibility.

Regardless of my age I agree to follow all of the MSHSL Bylaws in order to be eligible to represent my school in League-sponsored
activities.
I further understand that a member school of the MSHSL must adhere to all of the rules and regulations that pertain to the League
athletics/activities a school may sponsor and that local rules may be more stringent, and penalties more severe, than MSHSL rules.
STUDENT CODE OF RESPONSIBILITIES
As a student participating in my school’s interscholastic activities, I understand and accept the following responsibilities:

I will respect the rights and beliefs of others and will treat others with courtesy and consideration.

I will be fully responsible for my own actions and the consequences of my actions.

I will respect the property of others.

I will respect and obey the rules of my school and the laws of my community, state and country.

I will show respect to those who are responsible for enforcing the rules of my school and the laws of my community, state and country.
A student whose character or conduct violates the Student Code of Responsibilities or is suspended or expelled is not in good
standing and is ineligible for a period of time as determined by the principal. While a student not in good standing, a student
may not serve any penalty for MSHSL Bylaw violations.
Informed Consent: By its nature, participation in interscholastic athletics includes risk of injury and the transmission of infectious diseases
such as HIV, Herpes and Hepatitis B and others. Although serious injuries are not common and the risk of HIV transmission is almost
nonexistent in supervised school athletic programs, it is impossible to eliminate all risk. Participants have the responsibility to help reduce
that risk. Participants must obey all safety rules, report all physical and hygiene problems to their coaches, follow a proper conditioning
program, and inspect their own equipment daily. PARENTS, GUARDIANS OR STUDENTS WHO MAY NOT WISH TO ACCEPT
THE RISK DESCRIBED IN THIS WARNING SHOULD NOT SIGN THIS FORM. STUDENTS MAY NOT PARTICIPATE IN
AN MSHSL-SPONSORED ACTIVITY WITHOUT THE STUDENT’S AND PARENT’S/GUARDIAN’S SIGNATURE.
I consent to the athletic trainer or coach treating injuries and authorize them to discuss those injuries with and release any applicable medical
information or records relating to those injuries to coaches, school staff and other qualified health care providers as deemed necessary within
their scope of practice.
I further understand that in the case of injury or illness requiring transportation to a health care facility, that a reasonable attempt will be
made to contact the parent or guardian in the case of the student-athlete being a minor, but that, if necessary, the student-athlete will be
transported via ambulance to the nearest hospital.
By signing this we acknowledge that we have read the information contained in the MSHSL Eligibility Brochure and Statement.
I/we acknowledge the electronic signature confirms I/we have read and reviewed the information contained in the contents of the Eligibility
Brochure and Statement. I/we also acknowledge this electronic signature has the same legal effect, validity, and enforceability as a signature
in a non-electronic form.
The student/parent authorizes the release of documents and other pertinent information by the school in order to determine student eligibility. In
addition, the student/parent understands and agrees that public information shall include names and pictures of students participating in or
attending extra-curricular activities, school events, and High School League activities or events.
_____________________________________________________________________________________________________________
Student’s Printed Name
Birth Date
Grade in School
_____________________________________________________________________________________________________________
Student’s Signature
Date
_____________________________________________________________________________________________________________
Parent’s or Guardian’s Signature
Date
MSHSL ANNUAL SPORTS HEALTH QUESTIONNAIRE
DATE
_____ / _____ / __________
Name ______________________________________
Grade ____
Male
School ________________________________
Female
Age _____
Birth Date _____ / ______ / _________
Sport(s) ______________________________________________
Address ___________________________________________________________________________________________________
Phone
___________________________
Date of Last Sports Qualifying Physical Exam (SQPE) _____ / ______ / _________
Check Yes or No boxes for each question or Circle question numbers for which you cannot answer.
IN THE LAST YEAR, since your last complete Sports Qualifying Physical Exam with your physician or your Year 2 Annual Health
Questionnaire, HAVE YOU HAD ANY CHANGES TO THE FOLLOWING QUESTIONS:
YES
NO
1. In the last year, has a doctor restricted your participation in sports for any reason without clearing you to return to sports? ..............
IMPORTANT HEART HEALTH QUESTIONS ABOUT YOU IN THE LAST YEAR
2. In the last year, have you passed out or nearly passed out during or after exercise?.........................................................................
3. In the last year, have you had discomfort, pain, tightness, or pressure in your chest during exercise? ..............................................
4. In the last year, does your heart race or skip beats (irregular beats) during exercise? .......................................................................
5. In the last year, do you get light-headed or feel more short of breath than expected during exercise? ...............................................
6. In the last year, have you had an unexplained seizure? ....................................................................................................................
IMPORTANT HEART HEALTH QUESTIONS ABOUT YOUR FAMILY IN THE LAST YEAR
7. In the last year, has anyone in your immediate family died suddenly and unexpectedly for no apparent reason? ..............................
8. In the last year, has any family member or relative died of heart problems or had an unexpected or unexplained sudden death
before age 50 (including an unexplained drowning, an unexplained car accident, or Sudden Infant Death Syndrome)? ....................
9. In the last year, has anyone in your immediate family had instances of unexplained fainting, seizures, or near drowning? ................
10. In the last year, has anyone in your immediate family developed hypertrophic cardiomyopathy, Marfan Syndrome, arrhythmogenic
right ventricular cardiomyopathy, long QT Syndrome, short QT Syndrome, Brugada Syndrome, or catecholaminergic polymorphic
ventricular tachycardia? ....................................................................................................................................................................
11. In the last year, has anyone in your immediate family been diagnosed with Marfan Syndrome, arrhythmogenic right ventricular
cardiomyopathy,long or short QT Syndrome, Brugada Syndrome, or catecholaminergic polymorphic ventricular tachycardia? .........
12. In the last year, has anyone in your immediate family under age 50 had a heart problem, pacemaker, or implanted defibrillator? .....
MEDICAL RISK QUESTIONS IN THE LAST YEAR
13. Have you had infectious mononucleosis (mono) within the last month? .............................................................................................
14. In the last year, have you had a head injury or concussion that still has symptoms like continuing headaches, concentration problems
or memory problems? .......................................................................................................................................................................
15. In the last year, have you had numbness, tingling, weakness in, or inability to move your arms or legs after being hit or falling? ......
Parents or Legal Guardians: Please note below any health concerns, medications, or allergies that may be important
for the coaches or athletic/activities director to know.
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
I do not know of any existing physical or additional health reason that would preclude participation in sports. I certify that the answers to the above
questions are true and accurate and I approve participation in athletic activities.
________________________________________________
Parent or Legal Guardian Signature
________________________________________________
Athlete Signature
_________________
Date
Athletic/Activity Director Notes: (a YES answer to any of the questions above
requires a clearance note from a physician prior to participation.)
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
SQPE Due ____ / _____ / ________
CLEARED FOR SPORTS: YES
NO
Reference: Preparticipation Physical Evaluation (Third Edition): AAFP, AAP, AMSSM, AOSSM, AOASM ; McGraw-Hill, 2004.
Revised 4/9/13