2019-2020 Midland Middle School Athletic Registration
This registration form is only good for one student. If you have multiple students in your home that will participate, each one will need to be logged individually by clicking submit another response at the end of the form. If the student is in high school, you'll need to go back to the presentation and click on the MHS link to complete the high school athlete registration.
Student's Name: *
Your answer
Parent's Name: *
Your answer
Address: *
Your answer
Parent's phone number: *
Your answer
Emergency contact information: *
In case we can't reach you, who can we call?
Your answer
Student's birthday: *
Your answer
Grade entering Fall 2019 *
My student athlete and I have read and agree to the IESA concussion form. *
Required
Student-athlete Medical Information
Family Doctor *
Please list the doctor's name and phone number
Your answer
Emergency contact *
Please list at least one person we may contact in the event we can't reach a parent or guardian and their relationship to the student-athlete.
Your answer
Proof of Insurance *
If your student athlete is participating in an athletic sport, we need to know that they have accident/health insurance and that they are covered during an athletic contest. Please include the name of the insurance company and a policy number.
Your answer
Please list any previous medical conditions including allergies, medications, conditions, and any known restrictions. *
Your answer
In the event of a medical emergency and if reasonable attempts to contact me using the telephone numbers listed above are unsuccessful I, as parent or legal guardian of the student athlete, do hereby authorize: Treatment by a licensed medical physician of my child in the event of a medical emergency that in the opinion of the attending physician, may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed, and transfer of my child to any hospital reasonably accessible at my expense. *
Midland Middle School Athlete Registration
Midland Middle School Handbook: This page will serve as your final step for registration. Please click on the link for a copy of the Midland Middle School Handbook.
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