Alden-Conger Public School District

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2024-2025 MSHSL Eligibility Statement & Annual Sports Health Questionnaire

Please complete the form below. Required fields marked with an asterisk *
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MSHSL Eligibility Statement

All MSHSL eligibility determinations are based on the most current official handbook on the MSHSL website at:  www.mshsl.org/governance 

Statement to be signed by the participant from a MSHSL member school and by the participant’s parent or guardian each school year prior to participation in that year. Please check all items: *
Answer required for "Statement to be signed by the participant from a MSHSL member school and by the participant’s parent or guardian each school year prior to participation in that year. Please check all items: "

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. 

I am a home school student.*
Answer required for "I am a home school student."
I am an online student.*
Answer required for "I am an online student."

MSHSL Annual Sports Health Questionnaire

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: 

1. In the last year, has a doctor restricted your participation in sports for any reason without clearing you to return to sports?*
Answer required for "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?*
Answer required for "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?*
Answer required for "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?*
Answer required for "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?*
Answer required for "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?*
Answer required for "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?*
Answer required for "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 35 (including an unexplained drowning or an unexplained car accident)?*
Answer required for "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)?"
9. In the last year, has anyone in your immediate family had instances of unexplained fainting, seizures, or near drowning?*
Answer required for "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 been diagnosed with hypertrophic cardiomyopathy, Marfan Syndrome, arrhythmogenic right ventricular cardiomyopathy, long or short QT Syndrome, Brugada Syndrome, or catecholaminergic polymorphic ventricular tachycardia?*
Answer required for "10. In the last year, has anyone in your immediate family been diagnosed with hypertrophic cardiomyopathy, Marfan Syndrome, arrhythmogenic right ventricular cardiomyopathy, long or short QT Syndrome, Brugada Syndrome, or catecholaminergic polymorphic ventricular tachycardia?"
11. In the last year, has anyone in your immediate family under age 35 had a heart problem, pacemaker, or implanted defibrillator?*
Answer required for "11. In the last year, has anyone in your immediate family under age 35 had a heart problem, pacemaker, or implanted defibrillator?"

MEDICAL RISK QUESTIONS IN THE LAST YEAR

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?*
Answer required for "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?"
13. In the last year, have you had COVID-19 illness with trouble breathing; persistent chest pressure; confusion; inability to stay awake; high fever for more than 4 days; pale, gray, or blue-colored skin, lips, or nail beds; or hospitalization and not been approved for return to sports by a physician?*
Answer required for "13. In the last year, have you had COVID-19 illness with trouble breathing; persistent chest pressure; confusion; inability to stay awake; high fever for more than 4 days; pale, gray, or blue-colored skin, lips, or nail beds; or hospitalization and not been approved for return to sports by a physician?"

A YES answer to any of the medical questions above requires a clearance note from a physician prior to participation.

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.  This includes agreeing to all aspects of the MSHSL Eligibility Statement.

Parent's or Guardian's Signature*
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REMEMBER TO RETURN YOUR ORIGINAL REGISTRATION FORM TO COMPLETE YOUR REGISTRATION.

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