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