Athlete Registration Form
Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Female
Male
The athlete have any chronic medical illnesses such as diabetes, asthma (exercise asthma), kidney problems, etc.?
Yes
No
Please explain
The athlete have any allergies?
Yes
No
Please explain
Please upload medical health document(s) (if applicable)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Physician Name
First Name
Last Name
Physician Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance
Insurance Company
Insurance Policy #
Insurance Group #
Parent/Guardian & Emergency Contact
I, the athlete, agree with the following statements:
I am physically able to take part in the activities.
I know there is a risk of injury. I understand the risk of continuing to play sports with or after a concussion or other injury. I may have to get medical care if I have a suspected concussion or other injury. I also may have to wait 7 days or more and get permission from a doctor before I start playing sports again.
I will respect and obey all laws and the athlete's Code of Conduct.
Date
 -
Month
 -
Day
Year
Date
Signature (Athlete or Parent/guardian)
Submit
Should be Empty: