Athletic Student Information


Student Namerequired
First Name
Last Name
Current Graderequired
Select Schoolrequired
Date of Birthrequired
Must contain a date in M/D/YYYY format
Student Cellular Phone
Email Address
Parent/Guardian Namerequired
First Name
Last Name
Daytime Phone
Parent/Guardian Cellular Phonerequired
Alternate Emergency Contact Personrequired
Phone Numberrequired


Medical Insurance Companyrequired
Policy #required
Family Physicianrequired
Phone Numberrequired
List Allergies or Special Conditionsrequired
State none if applicable ​

NOTE: In the event of a medical emergency situation, even with the form, the chaperone will attempt first to contact the student's parent/guardian.