REGISTRATION FORM FOR FALL INTRAMURAL SPORTS
PLEASE PRINT:
NAME: _________________________________________________ PHONE # _____________
TEACHER'S NAME: _________________________ GRADE ________ AGE ______________
(Please circle) BOY/GIRL (Please circle) T-SHIRT SIZE: YOUTH S M L
ADULT S M L
NAME OF PARENT OR GUARDIAN:_______________________________________________
PHONE NUMBERS: Home:____________________ Cell:________________ Work:________
PARENT EMAIL ADDRESS: ______________________________________________________
PHYSICIAN'S NAME:_______________________ PHONE #____________ CHART # ________
REGISTRATION FEE: SOCCER $60 ( ) CROSS-COUNTRY $60 ( )
PARENT'S SIGNATURE: ____________________________________DATE:________
Person to contact in case of illness, if parents cannot be reached:
Name: _______________________________________ Phone #: _______________________
Name: _______________________________________ Phone #: _______________________
Does your child have: Fainting spells __________ Diabetes ___________ Epilepsy_______
Heart Condition __________ Allergies _________________________
Other chronic or unusual conditions: _______________________________________________
____________________________________________________________________________
Please note any information the school should have regarding your child's health.
_____________________________________________________________________________
_____________________________________________________________________________
Please list all current medication and reasons:
______________________________________________________________________________
______________________________________________________________________________
l. Do you grant permission for first aid and over-the-counter medication (non-aspirin, antiseptics, anti-nausea, diarrhea, eye drops, etc.)? YES ________ NO _________
2. Do you grant permission, if emergency treatment is required, to call another physician if above named physician is not available? YES __________ NO _________________
Registration form(s) and applicable fee(s) is/are due by Wednesday, August 18, 2010.
