IREDELL COUNTY YOUNG ATHLETE’S ASSOCIATION
ATHLETIC PARTICIPATION FORM
(ICYAA)
Both sides of this form are to be filled out completely and filed in the presence of the Director or
coach of the sport before the student can participate in the Iredell County Young Athlete’s
Association’s athletic programs.
STUDENT ______________________________________________________________________
SCHOOL ________________________________________________________________________
ADDRESS ______________________________________________________________________
GRADE ___________________________________
PARENT’S NAME ____________________________ PHONE #s: (Home) _____________________
FAMILY PHYSICIAN _________________________ (Work) ___________________________
(Cell) __________________________
PERMISSION TO PARTICIPATE
(to be completed and signed by the student and parent/guardian)
I have read and reviewed the general requirements for ICYAA athletic eligibility on the reverse
side. I understand that additional questions or specific circumstances should be directed to the
Director, or Coach.
I certify that the home address of parents shown above is my sole bona fide residence and I will
notify the Director or Coach
immediately of any change in residence, since such a move may alter the eligibility status of my
child.
As a parent or legal guardian of ________________________________, in accordance with the
rules of ICYAA, I hereby give my consent for his/her participation in interscholastic sports in the
Iredell County Young Athlete’s Association..
I grant permission for first aid treatment deemed necessary for a condition arising during
participation in these activities, and medical or surgical treatment recommended by a medical
doctor. I understand that every effort will be made to contact me prior to treatment.
I also acknowledge that there is a certain risk of injury involved with athletic participation; even
with the best coaching, use of the most advanced protective equipment and strict observance
of the rules, injuries are still a possibility and in rare occasions these can be so severe as to
result in disability, paralysis or even death. It is impossible to eliminate the risk.
I agree to the need for a medical examination and I certify that the medical history on reverse
side is accurate to the best of my knowledge. I understand that failure to comply with ICYAA
policies and NCHSAA policies that govern athletics are grounds for suspension and/or dismissal
from athletic participation.
I certify that the information in this application is correct, and I agree to abide by the eligibility
rules and regulations governing athletics as set forth by the Iredell County Young Athlete’s
Association, N.C State Board of Education, the N. C. Department of Public Instruction, and the
North Carolina High School Athletic Association..
In consideration of being allowed to participate in the ICYAA program, the athlete and the
parent/guardian of the athlete do hereby agree, for ourselves, our heirs, executors and
administrators, to release, hold harmless and forever discharge the ICYAA, their employees,
officers, directors, administrators, agents, representatives, students, affiliates, subsidiaries,
successors, and assign, for and against any and all claims, actions, causes of action, suits,
judgments, and demands whatsoever arising directly or indirectly in connections with the
participation. By signing below, I acknowledge that I have read and understand this form and
further understand that the terms herein are contractual and not a mere recital.
Date__________________
Signature of Student Athlete_____________________________________________________
Date_____________________
Signature of Parent or Guardian___________________________________________________