Athletics Registration

* fields are required

Student Information

Student Name:*

Grade:*

Sex:*

Date of Birth:

Sport:

Parent/Guardian Information

Parent/Guardian Name:*

Address:*

City:*

Zipcode:*

Father Daytime Phone:*

Father Cell Phone:

Father E-Mail Address:*

Mother Daytime Phone:*

Mother Cell Phone:

Mother E-Mail Address:*

Emergency Contact Information

Emergency Contact Name:*

Emergency Contact Phone:*

Relationship to Student:*

Medical/Dental Information

Please Read and Agree to the Following Statement:
I hereby give my consent for medical/dental treatment deemed necessary by physicians designated by school authorities and/or for transportation to a hospital emergency room for treatment for any illness or injury resulting from his/her athletic participation. I understand this authorization will only be enforced when I cannot be personally contacted and provide for immediate treatment.
I Agree *

Date of Students Last Physical:*

Primary Care Physician Name:*

Physician Phone:*

Physician Address:

Physician City:

Physician Zipcode:

Dentist Name:*

Dentist Phone:*

Dentist Address:

Dentist City:

Dentist Zipcode:

Health Information:*

HEALTH INFORMATION: Please ist any significant or on-going health conditions relevant to school or athletics (severe allergies/epi-pen, asthma, ADD, birth defects, diabetes, epilepsy, heart disease, vision or hearing problems, medications, etc.) Please enter N/A for no health issues.

Insurance Information

I have purchased an accident insurance plan from or am covered under a family medical plan.

I DO NOT have insurance, and I will assume responsibility for payment of expenses incurred in the event of injury to my son/daughter. Holy Family High School will not be held responsible for any medical bills or debts resulting from any injury to the above named athlete while participating in any scrimmage or contest.

Statement of Agreement and Digital Signature

Parent Statement:
I UNDERSTAND THAT MY SON/DAUGHTER MAY BE INJURED WHILE PARTICIPATING IN SCHOOL SPONSORED ATHLETICS. I HEREBY GRANT PERMISSION TO THE TEAM PHYSICIAN AND CERTIFIED ATHLETIC TRAINER TO ADMINISTER ANY PREVENTATIVE, FIRST AID OR EMERGENCY TREATMENTS THAT THEY DEEM REASONABLY NECESSARY TO THE HEALTH AND WELL-BEING OF MY STUDENT ATHLETE. I UNDERSTAND THE CERTIFIED ATHLETIC TRAINER MAY OFFER MY STUDENT ADVICE CONCERNING NUTRITION, HYDRATION, ULTASOUND, ELECTRICAL STIMULATION, AND WHIRLPOOL TREATMENT.
Parent Agreement*

Student Statement:
I UNDERSTAND THAT I MAY BE INJURED WHILE PARTICIPATING IN SCHOOL SPONSORED ATHLETICS. I HEREBY GRANT PERMISSION TO THE TEAM PHYSICIAN AND CERTIFIED ATHLETIC TRAINER TO ADMINISTER ANY PREVENTATIVE, FIRST AID OR EMERGENCY TREATMENTS THAT THEY DEEM REASONABLY NECESSARY TO MY HEALTH AND WELL-BEING.
Student Agreement*

Terms of Agreement

**PLEASE NOTE YOU WILL NEED TO TURN IN YOUR ACTIVITIES/PHYSICAL RELEASE TO THE ATHLETIC DEPARTMENT BEFORE YOU RECIEVE YOUR PURPLE PASS. IF YOUR PHYSICAL IS NOT CURRENT- YOU CAN PRINT A COPY OF THE RELEASE FORM FROM THE ATHLETICS PAGE ON THE WEBSITE.**

Agreement to Terms*

Helpful Links

Athletics Registration