Fee Waiver Request Form

Spring 2019-20 Athletics Participation Fee Waiver Request Form

This form must be completed for each student and in each athletics season that an athletics participation fee waiver is being requested.

Waiver requests must be submitted at least two (2) days prior to the due date for payment of athletics participation fees (March 9).Completed forms can be turned in to the MSHS Athletics Office (1203 W. Fair Avenue) or submitted via e-mail to atiseo@mapsnet.org.

Student Information

Student Name *

Grade Attended for 2019-20: *

Date of Birth *

Address *

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

E-mail *

Sport Waiver Requested For

Other sports student will be participating in during 2019-20

Has this student transferred to MSHS from another high school within the past calendar year?

Yes
No

Does this student qualify for the free/reduced lunch program and has the required information been filed for 2019-20?

I currently qualify for the free/reduced lunch program.
I do not qualify for the free/reduced lunch program. I am applying for a partial waiver.

Please provide a detailed reason for waiver request *

Parent/Legal Guardian Information

Parent/Legal Guardian Name *

Phone *

Email *

For partial waiver requests, please specify what percentage of athletics participation fee will be covered by parent/legal guardian *

25%
50%
75%

Athletic Training Rules/Eligibility Agreement

I have thoroughly read and understand the training rules and scholastic eligibility criteria for participation in Marquette Senior High School athletics. I also agree to the terms outlined in the Athletic Code of Conduct, located in the Student/Parent Handbook.

Concussion Awareness Educational Material Acknowledgement

By my signature below, I acknowledge in accordance with Public Acts 342 and 343 of 2012 that I have received and reviewed the Concussion Fact Sheet for Parents and/or the Concussion Fact Sheet for Students provided by MARQUETTE AREA PUBLIC SCHOOLS ATHLETIC DEPARTMENT.

Student and Parent Acknowledgement of Risk and Release

Our signatures hereby acknowledge that we, the student athlete and parent or guardian, understand that by participating in athletics at Marquette Area Public Schools the student athlete will be exposed to the risk of serious injury, including but not limited to, the risk of sprains, fractures and ligament and/or cartilage damage which could result in a temporary or permanent, partial or complete impairment in the use of limbs; brain damage; paralysis; or even death. Having been so cautioned and warned that these injuries are possible, it is still our desire to have the student athlete named below participate in athletics.We hereby further acknowledge that the student athlete named below will be participating with full knowledge and understanding of the risk of serious injury to which they are exposing themselves by participating in athletics at Marquette Area Public Schools. I hereby release, discharge, and/or otherwise indemnify Marquette Area Public Schools and their employees against any claim by me on my behalf as a result of participation in MAPS athletics.

HIPAA Privacy and ATC FAST Track Authorization

I authorize UPHS and UP Sports Rehab Services Athletic Trainers/Medical Professionals to use and disclose protected health information pertaining to the above student during the 2019-20 academic year. In addition, I authorize the release of my student's medical form, information and any injuries related to his/her care in order to treat, consult, track and share information with other medical professionals using the ATC FAST Track System.

Pay-to-Participate Policy Acknowledgement *

I have read, understand, and agree to the Pay-to-Participate Policy.

Signatures

Student Signature *

Date

Parent Signature *

Date

Spring 2019-20 Athletics Participation Fee Waiver Request Form

Student Information

Parent/Legal Guardian Information

Signatures

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