26-27 Middle School Activities Participation Booklet

TO:  Parents of Student/Athletes  

FROM:  Belgrade Middle School Administration 

RE:  Sports Participation Forms 

 

Thank you for allowing your son or daughter to participate in our Activities Program. The Activities Program is designed to enhance the educational process by helping them to experience the many challenges that present themselves in interscholastic competition or by being involved in extracurricular activities. Our programs are for the student’s enjoyment and growth. The coaches, sponsors and I look forward to the opportunity to serve them. 

 

If you have any questions, please call the Middle School Office 924-2510  

 

Student-athletes are required to get a physical, complete a participation booklet with signatures from both the student and parent/guardian each school year.  The Middle School Office is open from 8:00 am to 4:00 pm Monday through Friday. 

 

COMPLETION OF DRAGONFLY PROFILE ALONG WITH THE PHYSICAL AND FEES ARE REQUIRED BEFORE THE FIRST PRACTICE! 

Both Students and Parents Must Sign and Date the following pages found online in the back portion of the Middle School Activities Participation Handbook. 

 

Acknowledgement of Activity Policies/Informed Consent and Insurance Status Verification Form  

Medical Treatment/Release form 

*Physical Form - Student signature on front and parent signature on back 

*Student-Athlete & Parent/Legal Guardian Concussion Statement  

*= Needed for athletic participation only 

 

PHYSICALS MUST BE COMPLETED BY A PHYSICIAN, PHYSICIAN ASSISTANT, OR NURSE PRACTITIONER DATED MAY 1, 2025 OR AFTER. 

 

The participation fees may be refunded to students who do not make the team or choose to drop the sport prior to the 1st competition date.  Refunds are not automatically mailed out.  Students or parents must contact the Middle School Office to request a refund.  

The Belgrade School District provides a wide range of extra-curricular activities for both boys and girls. Participation in these activities is voluntary. We feel participation in these activities can bring students many rewards. Participation requires the student to make a commitment to the activity, submit to the discipline of the coach, activities director, or advisor, and develop self-discipline to be successful. Participation requires considerable mental discipline and/or physical exertion and conditioning, as well as adherence to training rules and team or group regimens.  

 

We feel involvement in school activities provides students with an opportunity to be involved in a constructive endeavor. Students who are involved in activities tend to be good citizens and perform better in the academic arena. They go away from their school careers with a more positive feeling about their experiences. We believe parents should encourage their children to get involved in these activities as well as support them as they experience the challenges of their chosen endeavors. 

Belgrade School District believes that participation in extracurricular activities is a privilege extended to students who are willing to make a commitment to adhere to the rules that govern the program. It is the district’s belief that participation in organized activities can contribute to the all-around development of young men and women and implementation of the rules will serve the following purposes: 

 

1. To emphasize concern for the health and wellbeing of students. 

2. To provide a chemical-free environment that will encourage development of a healthy life-style. 

3. To promote self-discipline and a commitment to excellence among students.  

4. To confirm and support existing state laws which prohibits use of mood-altering chemicals and performance enhancing drugs. 

5. To emphasize standards of conduct in our students who, through their participation, are leaders and role models for their peers and younger students. 

6. To assist students who desire to resist peer pressure, which often directs them toward the use of chemicals. 

The provisions of this booklet include all students who are participating in any activity that is in addition to classroom instruction and have no bearing on course credit. This includes all athletics or any co-curricular clubs sponsored by Belgrade Schools. The adherence to these guidelines begins on the first day of their participation in any activity.  

Belgrade Schools further stipulate: 

Academics are the first responsibility of the student. Students are not in school for extra curricular activities, but are in extracurricular activities because of school.  

Local eligibility standards— All cases of eligibility arising that are not specifically provided for in this handbook shall be subject to the judgment of the school administrator. The administration’s decision will be final. Students must be in school the day of the activity in order to participate in that activity.  

 

• Missing/Incomplete assignments report and Office Referral Reports pulled every Wednesday at 3:30 PM during the season from the first day of each season.  

• Missing/Incomplete Assignments: 

  •  Any three or more missing/incomplete assignments would place students on probation. 

•  If a student on probation has three or more missing/incomplete assignments the following Wednesday, they would then become ineligible until the next Wednesday. 

•  Each student athlete is only allowed one Probationary period per activity season. 

• Behavior Report: 

•  One Office Referral verified by administration would place students on probation. 

•  Another Office Referral during the probation period, would make the student ineligible from the following Wednesday to Wednesday. 

 

For any unforeseen circumstances, a student athlete can appeal to the Activities Director for a possible second Probationary period. 

1. Physical Exam: Physical examination forms must be completed and turned in for all athletic activities before the student can begin practices. The current physical exam form is found in the participation booklet available on-line on the district's home page or at the Belgrade Middle School Office. 
2. Parent Meeting: Parents/guardians and students participating in an activity are invited to   attend an informational meeting to discuss and sign the activities guidelines. Parents are asked to attend these meetings for each activity.  Family members and fans of Belgrade Middle School student/athletes agree to serve as positive role models, treat all involved with respect, be supportive and encouraging.  There will be no toleration of unsportsmanlike behavior and if such behavior occurs this person will be asked to leave immediately and may also lose permission to attend future events. 
3. School Absences: Absences from school and participation in practices, games, meets or performances. 

1.  If you are absent from school for a school sponsored event you can practice, play in a game, or take part in a performance that day. 

2.  If you are absent from school for a limited number of periods for a medical, dental, optometrist, etc. appointment you can participate with approval from the administration  (principal, vice principal, or the activities director). A written excuse from the doctor is required.  

3. You may attend practice, play in games, or participate in performances with administrative approval if absent for a court appearance, bereavement, a family emergency, or some other reason deemed acceptable by the administration. 

4. If you are home sick and do not come to school for all or part of the day or are absent from any class (excused or unexcused) you cannot practice, play, or participate in performances. It is not in the best interest of our participants to be practicing when sick.  

5. If you are in school but are absent from class for reasons deemed unexcused, you may not participate in games, practices, or performances that day. 

 

500. School Suspension: School suspension includes suspension from school sponsored extracurricular activities. This will be treated as an unexcused absence from the activity.

5. Participation Fee Required: All students participating in middle school athletics will be required to pay $110 per sport/activity in 7th & 8th grades and $50 in 5th & 6th grades. The money raised from this fee helps with the financial support of the activity that the student benefits from. (Scholarships are available.  Please fill in the form on Dragonfly.) 

All participants shall abide by a code of conduct, which will earn them the honor and respect that participation and competition in the interscholastic program affords. Any conduct that results in dishonor to the student, team, group, or the school will not be tolerated. 

Behavioral Expectations: All activities participants will be expected to conform to all rules of conduct formulated by the coaches/advisors/directors, activities director, administration, and school board, including all expectations outlined in the Belgrade Middle School Student Handbook. Participants may be suspended from the squad or group for any action unbecoming of a participant representing Belgrade Schools. Activities participants should conduct themselves in an exemplary manner at all times. Belgrade Schools adheres to MHSA guidelines relating to the behavior of participants and spectators.  

 

1. Travel Requirements: All participants must travel to and return from all out of town activities with the team unless prior written permission is asked by their parents and granted by the administration. Participants will be released to travel with their parents/guardians only, after signing out with their coach/sponsor. 
2. Practice Expectations: All participants must attend all practices unless excused ahead of time by the coach/advisor/director. Unexcused absences will result in disciplinary actions as determined by the coach/advisor/activity director. 
3. Injuries: All injuries are to be reported immediately to the coach/advisor/activity director regardless of the nature of the injury. The coach/advisor/director will fill out an accident report form and file it in the principal’s office within one (1) school day of the accident. 
4. Confidentiality: Student report of a training rule violation will be held confidential. 
5. Hazing: Participating students will not be involved in hazing other students. Hazing is defined as any intentional, knowing, or reckless act directed against a student for the purpose of being initiated into, affiliated with, holding office in, or maintaining membership in a club or organization, or an athletic team whose members include other students. Participants will not force other members of a team or organization to do something that could be distasteful or dangerous. Students who are involved in hazing could be suspended from participation and possibly referred to law enforcement. 
6. Liability: The coach/advisor/director, any other member of the school staff, or any member of the Board of Trustees will not be held liable or responsible in case of an accident incurred during practice, games, meets, matches, tournaments, concerts, or trips supervised by Belgrade Public Schools. 
7. Serious Infractions: Participants charged with serious misdemeanors or felonies may be suspended from the activity pending disposition of the case. Following a conference with administration, head coach/advisor/director, activities director, and parents/guardian, the individual case shall be acted upon. 

Participants must abide by the terms of the District’s Chemical Dependency Prevention Policy and the following terms of these Activity Guidelines: 

1. No drinking or possession of alcoholic beverages 

2. No use or possession of illegal drugs or drug paraphernalia 

3. No use or possession of tobacco, nicotine products, or vaping materials in any form

4. No attendance at a party where alcohol/drugs are consumed 

Violations will be cumulative from the student’s first day of participation in any activity in the middle school and again at the high school.  A record of all violations will be kept by the activities director or the middle school principal. 

Middle School: The accumulation of offenses starts in fifth grade and continues through the eighth grade. Participants will no longer be eligible to participate after a second violation during their middle school experience.  

 

High School: The violation count starts anew upon entering the freshman year and continues through the participant’s senior year. Students will be dropped from participation if they receive three violations during this time period. 

 

Students who are found in violation of the chemical use policy at a school-sponsored event or on school sponsored trips will be disciplined under the provisions of the school discipline policy as well as the activities policy. 

 

Honesty Clause: Participants who violate the chemical use policy and admit to infractions will be penalized as stated per violation. Participants who deny that they have broken the chemical use policy and are later found guilty of violations will automatically be penalized by advancing to the next numerical step violation consequence.  

In addition, all participants are subject to the following consequences for violation of this policy: 

 

FIRST VIOLATION:  (DRUGS/ALCOHOL/TOBACCO):  Participants will be ineligible to compete in any games, contests, or performances for ten (10) school days from the date of disciplinary action. They will not be allowed to travel or sit with the team or group during performances or contests during this time.  Participants will continue to practice. The 10 school days will be carried over to the next activity and or school year.   

 

SECOND VIOLATION HIGH SCHOOL ONLY:  (DRUGS/ ALCOHOL/TOBACCO):  Participants will be suspended for 20 school days from the date of disciplinary action. They will not be allowed to travel or sit with the team or group during performances or contests. The 20 school days will be carried over to the next activity and or school year. 

 

THIRD VIOLATION HIGH SCHOOL OR SECOND VIOLATION MIDDLE SCHOOL:  (DRUGS/ALCOHOL/TOBACCO):  Students will be suspended from all extra-curricular activities for the remainder of their middle school or high school career. The activities director and principal will meet with the student and his/her parents/guardians to determine appropriate action.  Students eligible for reinstatement will be suspended for a minimum of 60 school days.  The 60 school days will be carried over to the next school year. 

1. The coach/advisor/director has the authority and the responsibility to suspend any participant from practice or competition for violation of activities policy until a meeting is arranged with parents or guardians. The coach/advisor/director or activities director will contact the parents/guardians within 24 hours if a participant is suspended. 
2. The coach/advisor/director or activities director has the authority to investigate if he/she suspects violation of the activities policy. 
3. Due process will be followed in each disciplinary case. The student and the coach/advisor/director will meet in conference with the parents or guardians prior to a student being dismissed from the team for a violation of training rules. The meeting will take place with the principal and/or activities director at the earliest convenient time. 

The purpose of this procedure is to encourage positive development of lifetime problem-solving skills. If a participant and/or parent/guardian have a concern with the activity in which the student is involved, they should communicate in the following order: 

Team Coach>Head Coach/Advisor/Director>Activities Director>Building Principal>Superintendent>School Board 

Students must obey curfew set by coaches and chaperones and be in their assigned hotel rooms on all school sponsored trips. Students may not be found in a room of the opposite gender and/or with someone they are romantically involved with at any time.  

Please read the following concussion information pages provided by the MHSA. 

 

A Fact Sheet For ATHLETES

 

WHAT IS A CONCUSSION? 

A concussion is a brain injury that: 

• Is caused by a bump or blow to the head 

• Can change the way your brain normally works 

• Can occur during practices or games in any sport 

• Can happen even if you haven’t been knocked out 

• Can be serious even if you’ve just been “dinged” 

 

WHAT ARE THE SYMPTOMS OF A CONCUSSION? 

• Headache or “pressure” in head 

• Nausea or vomiting 

• Balance problems or dizziness 

• Double or blurry vision 

• Bothered by light 

• Bothered by noise 

• Feeling sluggish, hazy, foggy, or groggy 

• Difficulty paying attention 

• Memory problems 

• Confusion 

• Does not “feel right” 

 

WHAT SHOULD I DO IF I THINK I HAVE A CONCUSSION? 

• Tell your coaches and your parents. Never ignore a bump or blow to the head even if you feel fine. Also, tell your coach if one of your teammates might have a concussion. 

• Get a medical checkup. A doctor or health care professional can tell you if you have a concussion and when you are OK to return to play. 

• Give yourself time to get better. If you have had a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have a second concussion. Second or later concussions can cause damage to your brain. It is important to rest until you get approval from a doctor or health care professional to return to play. 

 

HOW CAN I PREVENT A CONCUSSION? 

Every sport is different, but there are steps you can take to protect yourself. 

• Follow your coach’s rules for safety and the rules of the sport. 

• Practice good sportsmanship at all times. 

• Use the proper sports equipment, including personal protective equipment (such as helmets, padding, shin guards, and eye and mouth guards). In order for equipment to protect you, it must be: 

 

> The right equipment for the game, position, or activity 

> Worn correctly and fit well 

> Used every time you play 

Remember, when in doubt, sit them out! It’s better to miss one game than the whle season!

---

A Fact Sheet for PARENTS

WHAT IS A CONCUSSION?

A concussion is a brain injury. Concussions are caused by a bump or blow to the head. Even a “ding,” “getting your bell rung,” or what seems to be a mild bump or blow to the head can be serious.  

You can’t see a concussion. Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury. If your child reports any symptoms of concussion, or if you notice the symptoms yourself, seek medical attention right away.  

 

WHAT ARE THE SIGNS AND SYMPTOMS OF A CONCUSSION?  

Signs Observed by Parents or Guardians  

If your child has experienced a bump or blow to the head during a game or practice, look for any of the following signs and symptoms of a concussion:  

• Appears dazed or stunned  

• Is confused about assignment or position  

• Forgets an instruction  

• Is unsure of game, score, or opponent  

• Moves clumsily • Answers questions slowly  

• Loses consciousness (even briefly)  

• Shows behavior or personality changes  

• Can’t recall events prior to hit or fall  

• Can’t recall events after hit or fall  

 

Symptoms Reported by Athlete  

• Headache or “pressure” in head  

• Nausea or vomiting  

• Balance problems or dizziness  

• Double or blurry vision  

• Sensitivity to light  

• Sensitivity to noise  

• Feeling sluggish, hazy, foggy, or groggy  

• Concentration or memory problems  

• Confusion  

• Does not “feel right”  

HOW CAN YOU HELP YOUR CHILD PREVENT A CONCUSSION?  

Every sport is different, but there are steps your child can take to protect themselves from concussion.  

• Ensure that they follow their coach’s rules for safety and the rules of the sport.  

• Encourage them to practice good sportsmanship at all times.  

• Make sure they wear the right protective equipment for their activity (such as helmets, padding, shin guards, and eye and mouth guards). Protective equipment should fit properly, be well maintained, and be worn consistently and correctly.  

• Learn the signs and symptoms of a concussion.  

 

WHAT SHOULD YOU DO IF YOU THINK YOUR CHILD HAS A CONCUSSION?  

1. Seek medical attention right away. A health care professional will be able to decide how serious the concussion is and when it is safe for your child to return to sports.  

2. Keep your child out of play. Concussions take time to heal. Don’t let your child return to play until a health care professional says it’s OK. Children who return to play too soon—while the brain is still healing—risk a greater chance of having a second concussion. Second or later concussions can be very serious. They can cause permanent brain damage, affecting your child for a lifetime.  

3. Tell your child’s coach about any recent concussion. Coaches should know if your child had a recent concussion in ANY sport. Your child’s coach may not know about a concussion your child received in another sport or activity unless you tell the coach. 

Remember, when in doubt, sit them out! It’s better to miss one game than the whle season!

---

Be Prepared 

A concussion is a type of traumatic brain injury, or TBI, caused by a bump, blow, or jolt to the head that can change the way your brain normally works. Concussions can also occur from a blow to the body that causes the head to move rapidly back and forth. Even a “ding,” “getting your bell rung,” or what seems to be mild bump or blow to the head can be serious.   Concussions can occur in any sport or recreation activity.  So, all coaches, parents, and athletes need to learn concussion signs and symptoms and what to do if a concussion occurs. 

SIGNS AND SYMPTOMS OF A CONCUSSION 

SIGNS OBSERVED BY PARENTS OR GUARDIANS	SYMPTOMS REPORTED BY YOUR CHILD OR TEEN
•Appears dazed or stunned  •Is confused about events  •Answers questions slowly  •Repeats questions  •Can’t recall events prior to the hit, bump, or fall  •Can’t recall events after the hit, bump, or fall  •Loses consciousness (even briefly)  •Shows behavior or personality changes  •Forgets class schedule or assignments	Thinking/Remembering:  •Difficulty thinking clearly  •Difficulty concentrating or remembering  •Feeling more slowed down  •Feeling sluggish, hazy, foggy, or groggy  Physical:  •Headache or “pressure” in head  •Nausea or vomiting  •Balance problems or dizziness  •Fatigue or feeling tired  •Blurry or double vision  •Sensitivity to light or noise  •Numbness or tingling  •Does not “feel right”	Emotional:  •Irritable  •Sad  •More emotional than usual  •Nervous  Sleep*:  •Drowsy  •Sleeps less than usual  •Sleeps more than usual  •Has trouble falling asleep    *Only ask about sleep symptoms if the injury occurred on a prior day.

 

• CDC –Concussion in Sports 

  •  CDC 

• The National Federation of State High School Association/ Concussion in Sports - What You Need To Know 

  • NFHS 

• Montana High School Association – Sports Medicine Page

  • MHSA 

The School District DOES NOT provide medical insurance benefits for students who choose to participate in activities programs. 

If parents or guardians have their own insurance coverage during the student’s participation, that coverage information should be provided on the required “Informed consent and Insurance verification” form. If the student/athlete does not have current health insurance and wishes to purchase coverage or additional coverage, the district has cooperated with K & K Insurance to provide families with an option to purchase health coverage for the duration of the sport season or school year. If the family chooses to sign up with K & K Insurance the enrollment information is below.  

 

STUDENT/ATHLETE & PARENT/LEGAL GUARDIAN 

SIGNATURE BOOKLET 

Office Use Only  – Do Not Write in The Area Football___ Volleyball___ Cross Country ___ Wrestling___ Boys Basketball___ Girls Basketball___ Track___ Speech and Debate___ Science Olympiad___ Builders Club___ Drama Club___ Manager (Name Event)___ Other Club(s) ____

By signing below, you agree to the guidelines stated in the Activities Participation Booklet and adhere to its Chemical Use Policy during your season of participation. 

 

I have read and understand the activities policy included in this booklet. 

 

________________________________                  _______________________ 

Parent/Guardian Signature                                                      Date 

 

________________________________                  _______________________ 

Participant Signature                              Sport 

 

Belgrade Public Schools (School District #44) will not discriminate on the basis of sex, race, marital status, national origin, or disability in our educational programs or in our activities. All students will be treated equally.  

Extracurricular activities may include physical contact and physical exertion.  There is an inherent risk of injury in the activity.  By signing this agreement, I acknowledge that the School District staff try to prevent accidents. I agree to accept responsibility for my student’s participation in school activities. The activity is strictly voluntary.  

 

I, the undersigned, hereby acknowledge and understand that, regardless of all feasible safety measures that may be taken by the School District, participation in this event entails certain inherent risks.  I certify that my student is physically fit and medically able to participate or have noted an applicable physical or medical diagnosis at the bottom of this form.  I further certify that my student will honor all instructions of district staff and failure to honor instructions may result in dismissal from the activity. I have been informed of these risks, understand them, and feel that the benefits of participation outweigh the risks involved. My signature below gives my child permission to participate in a __________ School Activity. 

 

I authorize qualified emergency medical professionals to examine and in the event of injury or serious illness, administer emergency care to my student.  I understand every effort will be made to contact the family or contact person noted below to explain the nature of the problem prior to any involved treatment.  In the event it becomes necessary for the district staff in charge to obtain emergency care for my student, I understand that neither the district employee in charge of the activity nor the school district assumes financial liability for expenses incurred because of an accident, injury, illness and/or unforeseen circumstances.  

 

The School District DOES NOT provide medical insurance benefits for students who choose to participate in activities programs. If parents or guardians have their own insurance coverage during the student’s participation, that coverage information is provided below.  

____ I have personal medical insurance to cover the student’s participation: 

 

INSURANCE (Company Name) ____________________________________________ 

 

Policy # ________________________________________________________________ 

 

____ I do not have personal medical insurance to cover the student’s participation and understand that the School District does not provide medical insurance to cover the students. I understand I will be responsible for any medical costs associated with the student’s participation. 

 

Signature Required Regardless of Insurance Coverage: 

 

Student Athlete __________________________________________________________ 

 

                                (Please Print) 

 

Parent/Guardian _________________________________________________________ 

 

(Signature) 

Date: __________________________________________________________________ 

 

Because of the passage of the Dylan Steiger’s Protection of Youth Athletes Act, schools are required to distribute information sheets for the purpose of informing and educating student-athletes and their parents of the nature and risk of concussion and head injury to student athletes, including the risks of continuing to play after concussion or head injury.  Montana law requires that each year, before beginning practice for an organized activity, a student-athlete and the student-athlete’s parent(s)/legal guardian(s) must be given an information sheet, and both parties must sign and return a form acknowledging receipt of the information to an official designated by the school or school district prior to the student-athletes participation during the designated school year.  The law further states that a student-athlete who is suspected of sustaining a concussion or head injury in a practice or game shall be removed from play at the time of injury and may not return to play until the student-athlete has received a written clearance from a licensed health-care provider.  

 

Student-Athlete Name: ______________________________________________________  

This form must be completed for each student-athlete, even if there are multiple student-athletes in each household. 

 

Parent/Legal Guardian Name(s): ________________________________________________ 

 

□ We have read the Student-Athlete & Parent/Legal Guardian Concussion Information Sheet. 

If true, please check box 

 

After reading the information sheet, I am aware of the following information: 

Student-Athlete  Initials		Parent/Legal Guardian  Initials
	A concussion is a brain injury, which should be reported to my parents, my coach (es), or a medical professional if one is available.
	A concussion can affect the ability to perform everyday activities such as the ability to think, balance, and classroom performance.
	A concussion cannot be “seen.” Some symptoms might be present right away.  Other symptoms can show up hours or days after an injury.
	I will tell my parents, my coach, and/or a medical professional about my injuries and illnesses.	N/A
	If I think a teammate has a concussion, I should tell my coach(es), parents, or licensed health-care professional about the concussion.	N/A
	I will not return to play in a game or practice if a hit to my head or body causes any concussion-related symptoms.	N/A
	I will/my child will need written permission from a licensed health-care professional to return to play or practice after a concussion.
	After a concussion, the brain needs time to heal. I understand that I am/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 on the Concussion fact sheet.

 

Signature of Student-Athlete __________________________________ Date___________________ 

 

Signature of Parent/Legal Guardian _____________________________ Date___________________ 

To:  Parents and/or Guardians of Students Representing  

School District No. 44 in Activity Programs. 

 

It has become exceedingly difficult to obtain medical services for students injured when competing, without first obtaining parental/guardian consent in writing.  So that proper emergency assistance may be provided, we ask that you review the following statement, 

Sign and return to the faculty member in charge. 

I hereby authorize School District No. 44 and its faculty members in charge of my child named below to obtain all necessary medical care for my child and I hereby authorize Any licensed physician and/or medical personnel to render necessary medical treatment to my child. 

 

Print Student’s Name ___________________________________________________________ 

 

Signed ________________________________________________________________ 

(Parent and/or Guardian) 

Address________________________________________________________________ 

             ________________________________________________________________ 

Telephone No. __________________________________________________________ 

Date: _______________________________ 

 

Emergency Contact (Within 15 miles of Belgrade) 

Name: ______________________________________________________________________ 

Address:  ____________________________________________________________________ 

____________________________________________________________________________ 

Telephone No. ________________________________________________________________ 

Relationship to Student: _________________________________________________________ 

 

Allergies?  _________ YES _________ NO 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

 

Medication Needed __________ YES ____________ NO 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

 

Special Medical Problems?  _______ YES __________ NO 

_____________________________________________________________________________