Santiam Christian Athletic Participation and Emergency Form
Santiam Christian strives to protect each student from possible injury while engaging in school activities. The guidelines and/or practices identified below have been established for this activity in order to protect the student and others from injury and/or illness. Participants and their parents should recognize that conditioning, nutrition, proper techniques, safety procedures, and well-fitting equipment are important aspects of this training program.

Each participant is expected to follow the directions/standards of the coach. Every sport has certain inherent risks, and regardless of the precautions taken, it is impossible to guarantee the safety of the participant.

1. Student Athlete's Name *
Your answer
2. Participant's Grade: *
3a. Check a FALL sport in which the Student will be participating in this year: *
Please choose n/a if they aren't participating in a fall sport.
Required
3b. Check a WINTER sport in which the Student will be participating in this year: *
Please choose n/a if they aren't participating in a winter sport.
Required
3c. Check a SPRING sport in which the Student will be participating in this year: *
Please choose n/a if they aren't participating in a spring sport.
Required
4. AGREEMENT TO PARTICIPATE form I agree to follow all Santiam Christian rules and regulations as stated in the parent / student handbook associated with the participant's sport(s)? *
5. I certify that (a) the participant in question 1 is physically fit to participate in the sports checked from question 3, and I understand the same participant is free to discontinue activity at any time they feel undue discomfort or stress. *
6. I certify I have been provided with and read Santiam Christian High School’s Sports Medicine Concussion Information. I acknowledge receipt of this information in compliance with ORS417.875 (Jenna’s Law). I understand that on an annual basis, this Concussion Informed Consent Form shall be signed by myself and my student prior to participation in a practice, competition, or sports related activity. *
7. Parent/Guardian Full Name: (by inputting full name in this box I intend this to act as my legal signature and I certify that I am the parent/legal guardian of the participant listed in question 1 and the medical information in question 5 and 6 is correct and current) *
Your answer
8. Student Full Name: (by inputting full name in this box I intend this is my legal signature and I certify that the information in question 6 is correct and current) *
Your answer
Emergency Information
Parent(s) Name: *
Your answer
Parent's Phone #
Your answer
Parent Email address: *
Your answer
Insurance & Disclaimer
We acknowledge and recognize that hazards are present in athletic participation and that injury may result. My signature below authorizes Santiam Christian Schools to obtain any emergency medical transportation or care that may become necessary in the course of athletic activities.

In case of an emergency involving my student at an athletic event, contact parents or call the emergency person listed below:

Emergency Contact (other than parent) *
Your answer
Emergency Contact Phone # *
Your answer
Students participating in athletics are required to be covered by medical insurance. I have or will purchase medical insurance for my participating student and will continue to keep it current throughout the sports season. Any change in medical insurance between sports seasons must be reported. *
AGE ELIGIBILITY: (students cannot be 19 years old before August 15 of senior year) Will this student be 19 years old before August 15 of his/her senior year? *
RESIDENCE: Does this student reside at home with his/her parents? *
TRANSFER STATUS: Is this student a transfer to Santiam Christian this year? *
PHYSICAL EXAMINATION REQUIREMENT
State law requires students in grades 7-12 participating in school athletics to get a physical every two years. The OSAA examination form must be on file in the school office. If the student has had any serious accident, illness, or injury since the last physical examination, a physician’s clearance is necessary.
A. Has student had serious injuries or medical problems requiring medical attention within the last year? *
B. Does student have any ongoing significant disease or chronic illness such as epilepsy, diabetes, asthma, chronic heart disease, or severe allergies? *
If YES to either question A or B from above, please explain, if NO write N/A: *
Your answer
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