2022-2023 MSHSL Forms (Required yearly form to complete before registering for a MSHSL activity).

Student First and Last Name *

Student Birth Date (MM/DD/YYYY) *

Student Sex *

Female

Male

School the Student Attended Last Year: *

Richfield High School

Richfield Middle School

Homeschool

Other (specify below)

Student's School if you selected "Other" above:

MSHSL Eligibility Brochure Acknowledgement *

I have read understand and acknowledge receiving the 2021-2022 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 at: https://www.mshsl.org/about/mshsl-handbook

Concussion Management Recommendations *

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/headsup

Eligibility Rules Acknowledgement *

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.

MSHSL Bylaws Acknowledgment *

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.

Acknowledgement of Local Rules *

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 *

A student whose character or conduct violates the Student Code of Responsibilities or is suspended o...

As a student participating in school interscholastic activities I understand and accept the following responsibilities: (1) I will respect the rights and beliefs of others and will treat others with courtesy and consideration. (2) I will be fully responsible for my own actions and the consequences of my actions. (3) I will respect the property of others. (4) I will respect and obey the rules of my school and the laws of my community state and country. (5) 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.

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 AND PARENT/GUARDIAN SIGNATURE.

Medical Information *

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.

Parent or Guardian Contact *

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.

MSHSL Eligibility Statement Acknowledgement *

By signing this we acknowledge that we have read the information contained in the MSHSL Eligibility Brochure and Statement.

1. In the last year, has a doctor restricted your participation in sports for any reason without clearing you to return to sports? *

Yes

No

2. In the last year, have you passed out or nearly passed out during or after exercise? *

Yes

No

3. In the last year, have you had discomfort, pain, tightness, or pressure in your chest during exercise? *

Yes

No

4. In the last year, does your heart race or skip beats (irregular beats) during exercise? *

Yes

No

5. In the last year, do you get light-headed or feel more short of breath than expected during exercise? *

Yes

No

6. In the last year, have you had an unexplained seizure? *

Yes

No

7. In the last year, has anyone in your immediate family died suddenly and unexpectedly for no apparent reason? *

Yes

No

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 35 (including an unexplained drowning or an unexplained car accident)? *

Yes

No

9. In the last year, has anyone in your immediate family had instances of unexplained fainting, seizures, or near drowning? *

Yes

No

10. In the last year, has anyone in your immediate family been diagnosed with any of the following: *

hypertrophic cardiomyopathy, Marfan Syndrome, arrhythmogenic right ventricular cardiomyopathy, long ...

Yes

No

11. In the last year, has anyone in your immediate family under age 35 had a heart problem, pacemaker, or implanted defibrillator? *

Yes

No

12. In the last year, have you had a head injury or concussion that still has symptoms like continuing headaches, concentration problems or memory problems? *

Yes

No

Health Survey Question 1: Over the past 2 weeks, how often have you been bothered by the following problem: Feeling nervous, anxious, or on edge *

0 - Not at all

1 - Several Days

2 - Over half the days

3 - Nearly every day

Health Survey Question 2: Over the past 2 weeks, how often have you been bothered by the following problem: Not being able to stop or control worrying *

0 - Not at All

1 - Several Days

2 - Over half of the days

3 - Nearly every day

Are the sum of the values for your responses to the above Health Survey Questions 1 and 2 (listed above) greater than 2? *

For example, if you selected “1 – Several Days” for Health Survey Question 1, and “2 – Ove...

Yes (If yes please see your provider)

No

Health Survey Question 3: Over the past 3 weeks, how often have you been bothered by the following problem: Little interest or pleasure in doing things *

0 - Not at All

1 - Several Days

2 - Over half of the days

3 - Nearly every day

Health Survey Question 4: Over the past 4 weeks, how often have you been bothered by the following problem: Feeling down, depressed, or hopeless *

0 - Not at All

1 - Several Days

2 - Over half of the days

3 - Nearly every day

Are the sum of the values for your responses to the above Health Survey Questions 3 and 4 (listed above) greater than 2? *

For example, if you selected “1 – Several Days” for Health Survey Question 3, and “2 – Ove...

Yes; If yes please see your provider

No

Form Certification *

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.

MSHSL COVID-19 NOTICE *

In recognizing the serious nature of the COVID-19 pandemic and the positive impact that participatio...

I understand participating in MSHSL activities is voluntary.

I understand while participating in MSHSL activities, all laws as well as MSHSL and school rules, guidelines, and protocols related to COVID-19 must be followed.

The participant and parent/guardian acknowledges the contagious nature of COVID-19, and the Participant understands that there is risk of injury and/or illness from participating in MSHSL activities, including the risk to have direct or indirect contact with individuals who have been exposed to and/or diagnosed with COVID-19.

The participant agrees that if he/she is exposed to, or infected by, COVID-19 during the period of participation, they will immediately cease participation and follow Minnesota Department of Health protocols for schools and activities and MSHSL guidelines for notification and return to participation.

The participant has signed a separate Eligibility Statement connected to general participation in MSHSL athletics/activities and agrees that the terms of that statement are wholly incorporated into this document and that the terms of this document are incorporated into the Eligibility Statement.

Registration NOT complete acknowledgement *

By checking this box I acknowledge that my registration is NOT complete. The MSHSL forms is only one part of the registration process. Once I add this to my cart and process this free item I know I need to complete the registration by selecting the sport and completing contact and emergency information for their coach.

Parent/Guardian Electronic Signature Acknowledgement *

I acknowledge that by entering my name as the Parent/Guardian in the field below as an 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.

Parent/Guardian Signature *

Enter your full legal name as an electronic signature

Student Electronic Signature Acknowledgement *

I acknowledge that by entering my name as the Student in the field below as an 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.

Student Signature *

Enter your full legal name as an electronic signature

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