Student’s Name: Date: Dakota United CI Eligibility This form only needs to be completed for students who are invited to play for the Varsity team. This form only needs to be completed once during the course of a student’s participation as long as the student participates in consecutive seasons. If your student plans or wishes to be considered for the varsity team, please complete this form. There must be one form complete for each student in a family that wishes to participate in the varsity program. The Adapted Athletics: Cognitively Impaired Division is for students who are not able to compete in traditional, able bodied athletics through their home schools due to their low intellectual functioning. In order for a student to be able to participate at the varsity level, they must meet certain eligibility requirements. 1. Students must be classified Cognitively Impaired by their school district. Cognitively Impaired refers to students with significantly sub-average general intellectual functioning resulting in or associated with concurrent deficits in adaptive behavior. Significantly subaverage intellectual functioning must be indicated by an intelligence quotient (IQ) below 70 on an intelligence test that is standardized, nationally normed, technically adequate, and individually administered. Does your student have documentation that they meet this requirement? __________ Please attach a copy of the page from your student’s 3-year assessment that shows an IQ below 70. It may be called a “full scale” score as well. The most common tests used are the WISC III and the Stanford Binet, though others are acceptable. 2. Players must have a current physical on file with their home schools. This must be updated every 3 years. Please be certain this is done. 3. Players must be in grades 7-12. A student’s eligibility extends for 4 years from their entry into 9th grade, and ends when their class graduates. What grade is your student in? ___________ If your student is in 12th grade, how many years have they been in high school? __________ 4. Players must be enrolled in a school district within Dakota County to play for Dakota United Adapted Athletics. What school does your child attend? _________________ What district? _______________ 5. Players may not participate in an Adapted Program and an Able Bodied Interscholastic Program in the same season. Parent Signature: Date: