School Name:

 

Fall:

CLEARED

FOR PRACTICE

Winter:

CLEARED

FOR SCRIMMAGE OR COMPETITION

Spring:

NOT CLEARED

FOR SCRIMMAGE OR COMPETITION

 

PHYSICAL EXPIRATION DATE:_____/____/_____

NAME:

BIRTHDAY:

AGE:

SEX:

GRADE:

ADDRESS:

CITY:

ZIP CODE:

PARENT/GUARDIAN'S NAMES:

HOME PHONE:

FATHER'S PHONE DURING DAY:

MOTHER'S PHONE DURING DAY:

EMAIL ADDRESS:____________________________

IN AN EMERGENCY, IF PARENTS CANNOT BE REACHED, NOTIFY:

NAME:

PHONE:

FAMILY PHYSICIAN:

PHONE:

HOSPITAL

(Please indicate)

:

PHONE:

FAMILY DENTIST:

PHONE:

SCHOOL(S) ATTENDED LAST 12 MONTHS:

YEAR YOU ENTERED 9TH GRADE?

MONTH/YEAR YOU ENTERED HS?

HAVE YOU PREVIOUSLY ATTENDED THIS SCHOOL . . WITHDRAWN AND LATER RETURNED?

No

Yes

I hereby give my consent to release pictures, name or other information pertaining to my student/athlete to use on a district website.

I hereby give my consent for medical 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 personally be contacted and provide for immediate treatment.

Signed

(Parent or Guardian)

Date

School Name:

 

Fall:

CLEARED

FOR PRACTICE

Winter:

CLEARED

FOR SCRIMMAGE OR COMPETITION

Spring:

NOT CLEARED

FOR SCRIMMAGE OR COMPETITION

 

PHYSICAL EXPIRATION DATE:_____/____/_____

NAME:

BIRTHDAY:

AGE:

SEX:

GRADE:

ADDRESS:

CITY:

ZIP CODE:

PARENT/GUARDIAN'S NAMES:

HOME PHONE:

FATHER'S PHONE DURING DAY:

MOTHER'S PHONE DURING DAY:

EMAIL ADDRESS:____________________________

IN AN EMERGENCY, IF PARENTS CANNOT BE REACHED, NOTIFY:

NAME:

PHONE:

FAMILY PHYSICIAN:

PHONE:

HOSPITAL

(Please indicate)

:

PHONE:

FAMILY DENTIST:

PHONE:

SCHOOL(S) ATTENDED LAST 12 MONTHS:

YEAR YOU ENTERED 9TH GRADE?

MONTH/YEAR YOU ENTERED HS?

HAVE YOU PREVIOUSLY ATTENDED THIS SCHOOL . . WITHDRAWN AND LATER RETURNED?

No

Yes

I hereby give my consent to release pictures, name or other information pertaining to my student/athlete to use on a district website.

I hereby give my consent for medical 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 personally be contacted and provide for immediate treatment.

Signed

(Parent or Guardian)

Date

Office use

Paid:

 

SPORT

DOUGLAS COUNTY SCHOOL DISTRICT RE-1

ATHLETIC REGISTRATION/EMERGENCY INFORMATION CARD

DOUGLAS COUNTY SCHOOL DISTRICT RE-1

ATHLETIC REGISTRATION/EMERGENCY INFORMATION CARD

 

SPORT

Office use

Paid: