K12 Athletic Eligibility Intake Form

Parent / Guardian Name

Name of parent /guardian contacting us or completing this form.

First Name

Last Name

Student Name

List the primary child involved here. If any other children of your children are involved, identify them in the description box at the bottom of this form.

First Name

Last Name

Age and Grade of Student

ex. age 7, grade 1

Home Address

Phone

(###)

###

####

Second Phone

(###)

###

####

Second Email

Referral Source

Name of School Attending

Please provide the school name and district. If transferring, please provide the names of the schools transferring from and transferring into.

Name of Sport(s) Involved

Name of Coach(es) Involved (if known)

Name of Athletic Director (if known)

Brief Description of What Happened

Documents to be provided by client, if any

Possible documents: emails from AD on the issue, OHSAA documents or appeals