Athletic Eligibility & Participation Form

Student Information

• Student Full Name: ____________________________________________
• Date of Birth: ______________________ Age: ________________
• Home Address: _______________________________________________
• City: __________________ State: ______________ ZIP: ___________
• Primary Phone Number: _______________________________________

Parent / Guardian Information

• Parent/Guardian #1 Name: ______________________________________
• Relationship to Student: _______________________________________
• Phone Number: ________________________________________________
• Email Address: ________________________________________________

• Parent/Guardian #2 Name: ______________________________________
• Relationship to Student: _______________________________________
• Phone Number: ________________________________________________
• Email Address: ________________________________________________

School Enrollment Status

Is the student currently enrolled at Landrum Middle School (LMS)?

• [ ] Yes
• [ ] No

If YES,

• Current Grade Level:
• [ ] 6th
• [ ] 7th
• [ ] 8th

If NO, please indicate the student’s educational status (check one):

• [ ] Homeschooled
• [ ] Enrolled at another school (please specify): _______________________
• School Name: ________________________________________________
• Grade Level: ________________________________________________

Medical Eligibility

Has the student had a sports physical within the last 12 months?

• [ ] Yes
• [ ] No

Date of Physical (if applicable): ___________________________________________

Name of Medical Provider or Facility: _______________________________________

Does the student have a history of injuries, medical conditions, or restrictions that may affect athletic participation?

• [ ] No
• [ ] Yes (please explain below): ___________________________________________

______________________________________________________________________

Transportation Acknowledgement

Transportation After Practice / Games

I acknowledge that my child will have reliable transportation home after all scheduled practices and games once the season begins.

• [ ] Yes, transportation is arranged for my student
• [ ] No (student may not participate until transportation is arranged)

Parent / Guardian Consent & Acknowledgement

I certify that the information provided on this form is accurate and complete to the best of my knowledge. I understand that participation in athletics involves physical activity and risk of injury. I grant permission for my child to participate in Landrum Middle School athletic activities, contingent upon meeting all eligibility and medical requirements.

Parent/Guardian Signature: _______________________________________________

Printed Name: ___________________________________________________________

Date: __________________________________________________________________

School Use Only

• [ ] Physical Verified
• [ ] Enrollment Verified
• [ ] Eligibility Approved

Coach / Athletic Director Signature: ________________________________________

Date: __________________________________________________________________

[Image: A lined worksheet with two logos of a lion’s head in a shield at the top corners. The page contains several sections of horizontal lines for writing.] [Image: A lined paper with two blue and white “Lions” logos at the top corners, featuring horizontal lines for writing.] [Image: A form titled “Transportation Acknowledgement” with sections for transportation arrangements after practice or games, parent/guardian consent, and signatures for parent/guardian and coach/athletic director.]