REQUEST FOR ATHLETIC ELIGIBILITY FOR SHARED SERVICES STUDENT


Date _____________________________

Student's name ___________________________________________________

Address __________________________________________________________

_________________________________________________________________

Date of birth ______________________

Date of entry into 9th grade or equivalent _____________________________

We hereby request athletic eligibility for him/her during the 200___ -  200___  school year.

According to the records examined, ___________________________ has met all other eligibility standards as regulated by the NYSPHSAA.

He/she anticipates participating in the following sports:

     Fall __________________________

     Winter _______________________

     Spring ________________________



Superintendent's signature _________________________________________

School district of student's residence ________________________________

Date ____________________________



Superintendent's signature _________________________________________

Host school district _______________________________________________

Date ____________________________



RETURN FOR FINAL APPROVAL TO:
Section XI
180 E Main St, Suite 302
Smithtown, NY  11787