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Must
pass
all
subjects
each
6-week
in
order
to
participate
on
an
Athletic
team.
Failure
to
pass
a
class
makes
a
student
ineligible
to
play
until
she
receives
passing
grades
in
ALL
classes
at
the
3-week
progress
report.
If
a
student
becomes
ineligible,
then
she
must
miss
3-
weeks
of
game
participation
but
is
still
required
to
practice.
If
a
student
repeatedly
fails
a
class,
then
she
will
not
be
considered
for
future
teams.
Any
student
entering
7th
grade
cannot
be
age
14
before
September
1,
2012.
Any
student
entering
8th
grade,
cannot
be
15
before
September
1,2012.
Supplies:
Running
shoes
are
required
(no
Keds
or
Sketchers),
socks
and
a
Vanston
Lady
Viking
workout
uniform.
All
girls
are
REQUIRED
to
purchase
a
practice
uniform
(t-shirt
and
shorts)
which
can
be
ordered
through
Coach
Turner.
If you choose to wear warm-ups during the winter months, they can be any color.
Failure to comply with dress regulations will result in points being deducted from their athletic grade.
Volleyball
Basketball
Cross Country
Track
August
October
November
February
November
December
March
May
Thursday
nights
Monday
and
Thursday
nights
Monday
or
Tuesday
nights
Monday,
Tuesday
or
Wednesday
night
**
There
is
a
Saturday
tournament
in
volleyball
and
basketball,
as
well
as
a
district
track
meet.
**
Participation
in
a
school
event
MUST
become
a
PRIORITY
BEFORE
OUTSIDE
ACTIVITIES
including
soccer,
drill
team,
and
dance.
Athletic
Guidelines:
All
school
rules
apply
to
our
athletes
and
in
many
cases
our
athletes
are
held
to
a
HIGHER
STANDARD.
The
following
are
policies
that
we
will
follow
throughout
the
athletic
season:
Be
a
GOOD
STUDENT
Academics
come
first
ALWAYS!
You
must
be
passing
ALL
classes
with
a
grade
of
70
or
higher
to
be
eligible
to
participate
on
a
school
athletic
team.
Grades
will
be
checked
each
six
weeks.
Citizenship
grades
of
A
should
be
maintained.
Lower
citizenship
grades
will
result
in
extra
conditioning
in
athletics.
Our
athletes
are
ROLE
MODELS
throughout
the
school
and
WE
EXPECT
ONLY
THE
BEST
FROM
OUR
ATHLETES
-
-
-
ON
AND
OFF
CAMPUS.
MORNING
EXPECTATIONS
All
athletes
are
expected
to
be
in
their
attendance
spots
no
later
than
8:15.
Athletes
will
be
counted
tardy
if
they
are
not
seated
at
that
time
and
1
point
will
be
deducted
from
their
grade.
ALL athletes are expected to be dressed for 1st period when they arrive in the mornings.
Page 1 of 4
Grade
Policy
Every
athlete
will
start
the
6-weeks
with
a
100.
EVERYDAY
the
girls
will
be
graded
on
the
following:
dressing
out,
jewelry,
attitude,
participation,
mile
time
(once
a
week)
and
tardiness.
Athletes
are
expected
to
be
dressed
in
athletic
attire,
tennis
shoes
and
hair
pulled
back
EVERYDAY!
Grade
Deductions
10
points-
Sitting
out
more
than
one
day
with
a
parent
note
(Only
one
parent
note
per
6-weeks
excuses
only
1
day)
or
failure
to
participate
and/or
failure
to
show
up
for
a
game
or
practice.
5 points- Failure to dressed out in appropriate athletic clothing and/or excessive walking during an activity.
2
points-
Jewelry
(NO
big
earrings,
rings,
watches,
and/or
bracelets),
long
hair
not
secured,
tardiness,
lockers
not
locked
after
practice
every
day,
missing
t-shirt,
and/or
shorts
or
shoes.
Athletes
can
lose
points
DAILY
for
the
things
listed
above.
In
addition,
athletes
can
lose
multiple
points
for
participation
and
attitude
in
a
given
day.
Dress
Code
All
athletes
will
be
checked
at
the
gym
door
before
leaving
first
period
to
make
sure
that
they
meet
dress
code
expectations.
Athletes
will
receive
3
warnings
before
receiving
an
office
referral.
If
an
athlete
forgets
her
clothes,
shoes
or
belt,
she
will
be
given
1
phone
call,
from
then
on
she
will
be
sent
to
the
office.
During
Season
Play
All
team
members
will
participate
in
the
games.
If
an
emergency
occurs,
please
notify
the
coach.
If
the
athlete
leaves
the
game
with
a
parent,
the
parent/guardian
must
sign
the
athlete
out
verifying
that
they
left
with
a
parent.
If
an
athlete
fails
to
have
a
parent/guardian
sign
them
out,
they
will
push
towels
the
following
morning
as
a
consequence.
We
encourage
you
and
your
athlete
to
support
their
teammates
whenever
they
can
by
staying
and
watching
their
games.
It
is
the
RESPONSIBILTY
of
the
athlete
to
let
their
coaches
know
when
they
are
not
going
to
be
in
attendance
for
an
event
1
week
prior
to
a
game
or
meet.
TUTORING
If
an
athlete
needs
tutoring
time
during
practice,
they
must
have
a
pass
signed
by
a
teacher
to
get
out
of
practice.
This
pass
will
also
need
to
be
initialed
by
the
teacher
upon
return
to
practice.
We
encourage
the
7th
grade
girls
during
volleyball
season
to
attend
tutoring
in
the
afternoon
because
of
practices
in
the
mornings
from
7
am
9am.
8th
grade
will
practice
in
the
afternoon
during
volleyball
season
from
3:30
pm
5:00
pm,
so
they
are
expected
to
attend
tutoring
in
the
morning.
Basketball
practice
is
in
the
mornings
for
7th
and
8th
grade,
so
they
will
need
to
attend
tutoring
in
the
afternoon.
Athletic
Consequences
Physical conditioning for various reasons: lost and found items, tardiness, classroom behavior, etc.
ONE
GAME
SUSPENSION
(may
vary
according
to
sport):
excessive
Tardies
4
or
more
tardies
to
practice
and/or
for
an
office
referral
due
to
classroom
tardiness.
Missed
practices
due
to
illness
or
appointment
will
be
left
to
a
coaches
discretion.
In
other
words,
the
coach
will
determine
the
consequences.
***
This
is
at
COACHES
discretion
***
COACHES
RESPONSIBILTIES
Willingness to commit the time, discipline, and work ethic to become a successful student/athlete
Practice and play with a positive attitude that will enhance teamwork and build a strong team
Treat
athletes,
coaches,
referees,
administration,
bus
drivers,
and
other
teams
with
respect.
Disrespecting
a
coach
or
a
referee
will
not
be
tolerated!
Be on time to practices and games. 4 or more tardies will result in a 1 game suspension.
Attend tutoring at times when it does not interfere with practice time
Communicate with coaches about injuries, tutoring, sectionals, grades, doctor appointments, etc.
Wear
appropriate
shoes
and
athletic
wear
to
practices
and
games.
No
jewelry
allowed.
Page 2 of 4
DO
NOT
ALLOW
YOUR
CHILD
TO
GET
THEIR
EARS
PIERCED
DURING
THE
ATHLETIC
SEASON
-
Jewelry
is
NOT
allowed
at
practice
or
games.
Parents
Responsibilities
Only
one
parent
note
will
only
be
ALLOWED
per
6-weeks
for
illness
or
injury.
It
will
only
excuse
athlete
for
one
day
of
practice.
Other
days
may
be
excused
with
the
presence
of
a
doctors
note.
Get your child to games and practices on time. 4 or more tardies will result in a one game suspension.
Athletes
must
be
picked
up
within
15
minutes
of
the
time
that
practices
or
a
game
end
or
upon
return
to
school
from
a
game.
Athletes
will
push
1
towel
for
every
minute
past
15-minutes.
If
your
child
participates
in
an
away
game,
you
MUST
sign
your
child
out
with
the
coaches
before
leaving
that
particular
event.
If
your
child
is
not
signed
out
by
a
parent,
consequences
will
be
given
the
following
day.
Consideration
for
8th
grade
athletics:
You must have tried out for a sport in the 7th grade
Awesome
attitude
We
truly
look
forward
to
working
with
you
and
your
daughter.
You
are
vital
to
our
success
and
we
appreciate
your
support
to
our
school,
staff
and
your
child.
Coach
Turner
Girls
Athletic
Coordinator
(972)
8825828
Please
SIGN
AND
RETURN
PAGE
4
of
the
packet,
The
Lady
Viking
Athletic
Contract.
Page 3 of 4
________________________________________________
Athlete
Name
______________________
Date
________________________________________________
Athlete
Signature
________________________________________________
Parent
Signature
Page 4 of 4
Grade:
Birthday:
Campus:
Home Address:
Home Phone:
Enter 10 digit number 9999999999
Mothers/Guardians Name:
Work Phone:
Work Phone:
Enter 10 digit number 9999999999
Cell Phone:
Cell Phone:
Enter 10 digit number 9999999999
Email Address:
Email Address:
Emergency Contact Information
(person to contact in case a parent cannot be reached)
Relationship to student:
Home/Cell Phone:
Work/Cell Phone:
Enter 10 digit number 9999999999
_________________________________________________________________________
Parent/Guardians Signature
_______________________________________
Date
______________________________________________________
Parent/Guardian Signature
_________________________________________________
Relationship
Notes:
THIS FORM
MUST
BE NOTARIZED
ACKNOWLEDGEMENT OF RULES
Attention School Authorities: This form must be signed yearly by both the student and parent/guardian and be
on file at your school before the student may participate in any practice session, scrimmage, or contest. A copy
of the students medical history and physical examination form signed by a physician or medical history form
signed by a parent must also be on file at your school.
Students Name:___________________________________________
Date of Birth:________________
To the Parent: Check any activity in which this student is allowed to participate.
Baseball
Football
Softball
Basketball
Golf
Swimming & Diving
Cross Country
Soccer
Team Tennis
Wrestling
Tennis
Track & Field
Volleyball
Date:____________
Signature of parent or guardian:____________________________________________________________
Street address:__________________________________________________________________________
City: ____________________________
Home Phone: _________________________
State: ________________
Zip: ________________
GENERAL INFORMATION
I understand that failure to provide accurate and truthful information on UIL forms could subject the
student in question to penalties determined by the UIL.
I have read the regulations cited above and agree to follow the rules.
____________________
________________________________________________________________
Date
Signature of student
Page 2
Mesquite ISD
Authorization For the Release of Medical Information
The Family Education Right to Privacy Act (FERPA) is a federal law that governs the release of a students
educational records, including personal identifiable information (name, address, social security number, etc.)
from those records. Medical information is considered a part of a student athletes educational record.
This authorization permits the athletic trainers, team physicians, and athletic staff (including coaches) of the
Mesquite ISD to disclose information concerning my medical status, medical condition, injuries, prognosis,
diagnosis, and related personal identifiable health information to the authorized parties listed below. This
information included injuries or illnesses relevant to past, present, or future participation in athletics.
The purpose of a disclosure is to inform the authorized parties of the nature, diagnosis, prognosis or treatment
concerning my medical condition and any injuries or illnesses. I understand once the information is disclosed it
is subject to re-disclosure and is no longer protected.
I understand that the Mesquite ISD will not receive compensation for its disclosure of the information. I
understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to
obtain treatment. I may inspect or copy any information disclosed under this authorization.
I understand that I may revoke this authorization at any time by providing written notification to the head
athletic trainer at the respective high school. I understand revocation will not have any effect on actions
Mesquite ISD has taken in reliance on this authorization prior to receiving the revocation. This authorization
expires six years from the date it is signed.
Medical information will be released to the following unless otherwise specified by the student athlete, parent,
or legal guardian. Initial or sign by the individual/group that you wish to exclude from disclosure.
Initials/Signature
Team Physicians and Medical Providers
Athletic Trainers
Medical Insurance Coordinators
Approved Research
Parents or Guardians
Coaches and Athletic Staff
Academic Counselors
Administrators & School Staff
College Coaches and Scouts
Student ID#
Printed Name of Parent/Legal Guardian (If student athlete is under 18 years of age)
Date
Date
REVISED 1-6-09
This MEDICAL HISTORY FORM must be completed annually by parent (or guardian) and student in order for the student to participate in athletic activities. These
questions are designed to determine if the student has developed any condition which would make it hazardous to participate in an athletic event.
Student's Name: (print) _______________________________________Sex __________ Age__________________Date of Birth ____________________________
Address _______________________________________________________________________________________Phone__________________________________
Grade_______________________________________ School ___________________________________________
Personal Physician ______________________________________________________________________________Phone__________________________________
In case of emergency, contact:
Name _________________________________Relationship __________________Phone (H) __________________(W) ___________________________________
Explain "Yes" answers in the box below**. Circle questions you don't know the answers to. Any Yes answer to questions 1, 2, 3, 4, 5, or 6 requires further
medical evaluation which may include a physical examination. Written clearance from a physician, physician assistant, chiropractor, or nurse practitioner is
required before any participation in UIL practices, games or matches
1.
Have you had a medical illness or injury since your last check
up or sports physical?
Have you been hospitalized overnight in the past year?
Have you ever had surgery?
Have you ever passed out during or after exercise?
Have you ever had chest pain during or after exercise?
Do you get tired more quickly than your friends do during
exercise?
Have you ever had racing of your heart or skipped heartbeats?
Have you had high blood pressure or high cholesterol?
Have you ever been told you have a heart murmur?
Has any family member or relative died of heart problems or of
sudden unexpected death before age 50?
Has any family member been diagnosed with enlarged heart,
(dilated cardiomyopathy), hypertrophic cardiomyopathy, long
QT syndrome or other ion channelpathy (Brugada syndrome,
etc), Marfan's syndrome, or abnormal heart rhythm?
Have you had a severe viral infection (for example,
myocarditis or mononucleosis) within the last month?
Has a physician ever denied or restricted your participation in
sports for any heart problems?
Have you ever had a head injury or concussion?
Have you ever been knocked out, become unconscious, or lost
your memory?
If yes, how many
When was the last
times?
concussion?
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Yes
No
13.
14.
15.
16.
Head
Neck
Back
Chest
Shoulder
Upper Arm
Elbow
Forearm
Wrist
Hand
Finger
Yes
No
Hip
Thigh
Knee
Shin/Calf
Ankle
Foot
It is understood that even though protective equipment is worn by the athlete, whenever needed, the possibility of an accident still remains. Neither the University
Interscholastic League nor the school assumes any responsibility in case an accident occurs.
If, in the judgment of any representative of the school, the above student should need immediate care and treatment as a result of any injury or sickness, I do hereby
request, authorize, and consent to such care and treatment as may be given said student by any physician, athletic trainer, nurse or school representative. I do hereby
agree to indemnify and save harmless the school and any school or hospital representative from any claim by any person on account of such care and treatment of said
student.
If, between this date and the beginning of athletic competition, any illness or injury should occur that may limit this student's participation, I agree to notify the school
authorities of such illness or injury.
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Failure to provide truthful responses could
subject the student in question to penalties determined by the UIL
Student Signature: _________________________________________Parent/Guardian Signature:____________________________________ Date: ________________
THIS FORM MUST BE ON FILE PRIOR TO PARTICIPATION IN ANY PRACTICE, SCRIMMAGE OR CONTEST BEFORE, DURING OR AFTER SCHOOL.
Weight________
Pulse __________
Corrected:
Pupils:
Equal
Unequal
As a minimum requirement, this Physical Examination Form must be completed prior to junior high athletic participation and
again prior to first and third years of high school athletic participation. It must be completed if there are yes answers to specific
questions on the student's MEDICAL HISTORY FORM on the reverse side. * Local district policy may require an annual physical
exam.
NORMAL
ABNORMAL FINDINGS
INITIALS*
MEDICAL
Appearance
Eyes/Ears/Nose/Throat
Lymph Nodes
Heart-Auscultation of the heart in
the supine position.
Heart-Auscultation of the heart in
the standing position.
Heart-Lower extremity pulses
Pulses
Lungs
Abdomen
Genitalia (males only)
Skin
Marfans stigmata (arachnodactyly,
pectus excavatum, joint
hypermobility, scoliosis)
MUSCULOSKELETAL
Neck
Back
Shoulder/Arm
Elbow/Forearm
Wrist/Hand
Hip/Thigh
Knee
Leg/Ankle
Foot
*station-based examination only
CLEARANCE
Cleared
Cleared after completing evaluation/rehabilitation for: __________________________________________________________
_________________________________________________________________________________________________________
Not cleared for:_________________________________________Reason: _________________________________________
Recommendations: _________________________________________________________________________________________
_________________________________________________________________________________________________________
The following information must be filled in and signed by either a Physician, a Physician Assistant licensed by a State Board of
Physician Assistant Examiners, a Registered Nurse recognized as an Advanced Practice Nurse by the Board of Nurse Examiners,
or a Doctor of Chiropractic. Examination forms signed by any other health care practitioner, will not be accepted.
Name (print/type) __________________________________________
Date of Examination:_______________________
Address:_____________________________________________________________________________________________
Phone Number: _______________________________________________________________________________________
Signature:____________________________________________________________________________________________
Must be completed before a student participates in any practice, before, during or after school, (both in-season and out-of-season) or games/matches.
Signs and Symptoms of Concussion The signs and symptoms of concussion may include but are not limited to: Head ache, appears
to be dazed or stunned, tinnitus (ringing in the ears), fatigue, slurred speech, nausea or vomiting, dizziness, loss of balance, blurry vision, sensitive to light or noise, feel foggy or groggy, memory loss, or confusion.
Oversight - Each district shall appoint and approve a Concussion Oversight Team (COT). The COT shall include at least one physician
and an athletic trainer if one is employed by the school district. Other members may include: Advanced Practice Nurse, neuropsychologist or a physicians assistant. The COT is charged with developing the Return to Play protocol based on peer reviewed scientific
evidence.
Treatment of Concussion - The student-athlete shall be removed from practice or competition immediately if suspected to have sustained a concussion. Every student-athlete suspected of sustaining a concussion shall be seen by a physician before they may return to
athletic participation. The treatment for concussion is cognitive rest. Students should limit external stimulation such as watching television,
playing video games, sending text messages, use of computer, and bright lights. When all signs and symptoms of concussion have cleared
and the student has received written clearance from a physician, the student-athlete may begin their districts Return to Play protocol as
determined by the Concussion Oversight Team.
Return to Play - According to the Texas Education Code, Section 38.157:
A student removed from an interscholastic athletics practice or competition under Section 38.156 may not be permitted to practice or
compete again following the force or impact believed to have caused the concussion until:
(1) the student has been evaluated, using established medical protocols based on peer-reviewed scientific evidence, by a treating physician chosen by the student or the student s parent or guardian or another person with legal authority to make medical decisions for the
student;
(2) the student has successfully completed each requirement of the return-to-play protocol established under Section 38.153 necessary
for the student to return to play;
(3) the treating physician has provided a written statement indicating that, in the physician s professional judgment, it is safe for the
student to return to play; and
(4) the student and the student s parent or guardian or another person with legal authority to make medical decisions for the student:
(A) have acknowledged that the student has completed the requirements of the return-to-play protocol necessary for the student to
return to play;
(B) have provided the treating physician s written statement under Subdivision (3) to the person responsible for compliance with the
return-to-play protocol under Subsection (c) and the person who has supervisory responsibilities under Subsection (c); and
(C) have signed a consent form indicating that the person signing:
(i) has been informed concerning and consents to the student participating in returning to play in accordance with the return-toplay protocol;
(ii) understands the risks associated with the student returning to play and will comply with any ongoing requirements in the
return-to-play protocol;
(iii) consents to the disclosure to appropriate persons, consistent with the Health Insurance Portability and Accountability Act of
1996 (Pub. L. No. 104-191), of the treating physician s written statement under Subdivision (3) and, if any, the return-to-play recommendations of the treating physician; and
(iv) understands the immunity provisions under Section 38.159.
Date
Student Signature
Date
SUDDENCARDIACARRESTAWARENESSFORM
RevisedJune2013
NameofStudent:__________________________________________________
WhatisSuddenCardiacArrest?
Occurssuddenlyandoftenwithoutwarning.
Anelectricalmalfunction(shortcircuit)causesthebottomchambersoftheheart(ventricles)to
beatdangerouslyfast(ventriculartachycardiaorfibrillation)anddisruptsthepumpingabilityof
theheart.
Theheartcannotpumpbloodtothebrain,lungsandotherorgansofthebody.
Thepersonlosesconsciousness(passesout)andhasnopulse.
Deathoccurswithinminutesifnottreatedimmediately.
WhatcausesSuddenCardiacArrest?
Conditionspresentatbirth
Inherited(passedonfromparents/relatives)conditionsoftheheartmuscle:
HypertrophicCardiomyopathyhypertrophy(thickening)oftheleftventricle;the
mostcommoncauseofsuddencardiacarrestinathletesintheU.S.
ArrhythmogenicRightVentricularCardiomyopathyreplacementofpartofthe
rightventriclebyfatandscar;themostcommoncauseofsuddencardiacarrestinItaly.
MarfanSyndromeadisorderofthestructureofbloodvesselsthatmakesthem
pronetorupture;oftenassociatedwithverylongarmsandunusuallyflexiblejoints.
Inheritedconditionsoftheelectricalsystem:
LonqQTSyndromeabnormalityintheionchannels(electricalsystem)oftheheart.
CatecholaminergicPolymorphicVentricularTachycardiaandBrugadaSyndrome
othertypesofelectricalabnormalitiesthatarerarebutruninfamilies.
NonInherited(notpassedonfromthefamily,butstillpresentatbirth)conditions:
CoronaryArteryAbnormalitiesabnormalityofthebloodvesselsthatsupplyblood
totheheartmuscle.Thesecondmostcommoncauseofsuddencardiacarrestin
athletesintheU.S.
Aorticvalveabnormalitiesfailureoftheaorticvalve(thevalvebetweentheheart
andtheaorta)todevelopproperly;usuallycausesaloudheartmurmur.
NoncompactionCardiomyopathyaconditionwheretheheartmuscledoesnot
developnormally.
WolffParkinsonWhiteSyndromeanextraconductingfiberispresentinthehearts
electricalsystemandcanincreasetheriskofarrhythmias.
Conditionsnotpresentatbirthbutacquiredlaterinlife:
CommotioCordisconcussionoftheheartthatcanoccurfrombeinghitinthechest
byaball,puck,orfist.
Myocarditisinfection/inflammationoftheheart,usuallycausedbyavirus.
Recreational/PerformanceEnhancingdruguse.
Idiopathic:SometimestheunderlyingcauseoftheSuddenCardiacArrestisunknown,evenafter
autopsy.
SUDDENCARDIACARRESTAWARENESSFORM
RevisedJune2013
Whatarethesymptoms/warningsignsofSuddenCardiacArrest?
Fainting/blackouts(especiallyduringexercise)
Dizziness
Unusualfatigue/weakness
Chestpain
Shortnessofbreath
Nausea/vomiting
Palpitations(heartisbeatingunusuallyfastorskippingbeats)
Familyhistoryofsuddencardiacarrestatage<50
ANYofthesesymptoms/warningsignsthatoccurwhileexercisingmaynecessitatefurther
evaluationfromyourphysicianbeforereturningtopracticeoragame.
WhatisthetreatmentforSuddenCardiacArrest?
Timeiscriticalandanimmediateresponseisvital.
CALL911
BeginCPR
UseanAutomatedExternalDefibrillator(AED)
WhatarewaystoscreenforSuddenCardiacArrest?
TheAmericanHeartAssociationrecommendsapreparticipationhistoryandphysicalincluding
12importantcardiacelements.
TheUILPreParticipationPhysicalEvaluationMedicalHistoryformincludesALL12of
theseimportantcardiacelementsandismandatoryannually.
Additionalscreeningusinganelectrocardiogramand/oranechocardiogramisreadilyavailableto
allathletes,butisnotmandatory.
Wherecanonefindinformationonadditionalscreening?
AmericanHeartAssociation(www.heart.org)
AugustHeart(www.augustheart.org)
ChampionshipHeartsFoundation(www.championshipheartsfoundation.org)
CypressECGProject(www.cypressecgproject.org)
ParentHeartWatch(www.parentheartwatch.com)
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Parent/GuardianSignature
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Parent/GuardianName(Print)
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StudentSignature
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StudentName(Print)