2018-2019 MPS Winter Sport Athlete Registration Form
The disclaimer information at the end of this form MUST be completed by a PARENT/GUARDIAN. Please note that a response of "disagree" to any of the questions will result in parent/guardian contact by activities director and may prevent student from participating in activity.
Student-Athlete Information
Gender of Student Athlete *
Please fill out form separately for each sport participating.
Sport Registering *
Please fill out form separately for each sport participating.
Athlete First Name *
Your answer
Athlete Last Name *
Your answer
Primary Mailing Address *
Street, City, State, Zipcode
Your answer
Athlete Email
Many coaches need this for software used during their season
Your answer
Athlete Cell #
555-555-5555
Your answer
Athlete Home Phone #
List a landline phone # if used (555-555-5555)
Your answer
Date of birth *
MM
/
DD
/
YYYY
Grade *
School *
T-shirt Size *
Parent/Family Information
Parent/Guardian 1 Name *
Your answer
Parent/Guardian 1 Phone # *
Give phone number that is most likely to be answered (usually cell - 555-555-5555)
Your answer
Parent/Guardian/Family 2 Name
Your answer
Parent/Guardian 2 Phone #
Give phone number that is most likely to be answered (usually cell 555-555-5555)
Your answer
Parent/Guardian Email
Your answer
Parent/Guardian Alternative Phone #
Give a parent's work telephone number if available
Your answer
Additional Emergency Contact Name *
Contact person for an emergency contact other than above listed parent/guardian(s)
Your answer
Additional Emergency Contact Phone # *
Give phone number that is most likely to be answered
Your answer
Medical History Information
Insurance Company *
If no insurance, answer "none"
Your answer
Policy # *
If no insurance, answer "n/a"
Your answer
List any allergies below *
Include food allergies and medication allergies. Answer "n/a" if no known allergies
Your answer
List any previous hospitalizations or previous surgeries below *
Include year and reason for hospitalization. Answer "n/a" if no prior hospitalization or surgery
Your answer
List any previous concussions below *
Include month and year. Answer "n/a" if no prior concussions
Your answer
List any current medications *
Include reason for taking medications. Answer "n/a" if no current medications
Your answer
List any other special medical concerns *
Answer "n/a" if no other concerns
Your answer
Disclaimers & Signatures
The following MUST be completed WITH a PARENT/GUARDIAN.
By choosing agree below I acknowledge that the information requested above is accurate and that the above named student has met all residency and academic requirements as established by the NDHSAA and Minot Public Schools (MPS). I acknowledge that I have received, reviewed, and understand MPS concussion protocol policy. I acknowledge that the above named student has a current, valid physical on file in the Activities Director’s office before taking part in any practice or game/meet. I acknowledge that participation in Minot Public School’s athletics includes risk of injury with may range in severity: from minor to disabling, to even death. I promise payment of participation fee prior to first contest ($50.00 for grades 9-12; $25.00 for 7th and 8th grades). I acknowledges that student/athlete will be responsible to follow all safety rules and report all physical problems to their coach or Sports Medicine staff, follow proper conditioning program, and inspect their equipment daily. I give permission for the above named student/athlete to accompany any school team, which he/she is a member of, on its local or out of town trips. Selecting agree commits the above named student/athlete not to use or possess alcohol, tobacco products, non-prescription drugs, and performance enhancing substances while a member of any Minot Public Schools athletic team or group. I give permission for the above named student to receive, through a medical doctor of the school’s choice, emergency medical care, which may become reasonably necessary in the course of such athletic activities or travel. I also guarantee the return of all school equipment, supplies, and uniforms as requested. Replacement costs and fees will be required for any items not returned on time or lost. *
Choose the appropriate answer.
By typing my name below I verify that I AM THE PARENT/GUARDIAN for this above mentioned student athlete and that I further agree not to hold the school or anyone acting in its behalf responsible for any injury occurring to the above named student in the proper course of such athletic activity or travel. I hereby give my consent to participate for the above-named student. *
Parent/Guardian type FIRST & LAST name below
Your answer
By typing my name & ID number below I, the STUDENT-ATHLETE named on this form, am verifying that I have read the foregoing and will abide by the principles and regulations contained therein. *
Student athlete name and school ID number
Your answer
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