CHS Athlete Registration 2018-2019
Last Name (of Athlete) *
Your answer
First Name (of Athlete) *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Student's Cell Phone
Your answer
Student's Email
Your answer
Intended Athletic Participation
Please select below the sports you/your child intends to participate in during each season of the 2017-2018 academic year.
Fall Sports Participation *
Winter Sports Participation *
Spring Sports Participation *
Medical Information
In the event of an emergency it is important that CHS Athletics have pertinent medical information. Please answer the following questions to the best of your knowledge. If you have no applicable answer please indicate with N/A.
Medical Conditions *
Please list and describe all medical conditions of your child/ward.
Your answer
Medical Allergies *
Please list all medical allergies of your child/ward. If he/she has none, please type none.
Your answer
Prescription Medications *
Please list all prescription medications of your child/ward.
Your answer
Food Allergies *
Please list any food allergies that your child/ward may have.
Your answer
Parent/Guardian Information
First and Last Name *
(Parent/Guardian 1)
Your answer
Cell Phone
(Parent/Guardian 1)
Your answer
Home Phone
(Parent/Guardian 1)
Your answer
Work Phone
(Parent/Guardian 1)
Your answer
Email
(Parent/Guardian 1)
Your answer
Street Address/City/State/Zip Code
(Parent/Guardian 1)
Your answer
First and Last Name
(Parent/Guardian 2)
Your answer
Cell Phone
(Parent/Guardian 2)
Your answer
Home Phone
(Parent/Guardian 2)
Your answer
Work Phone
(Parent/Guardian 2)
Your answer
Email
(Parent/Guardian 2)
Your answer
Street Address/City/State/Zip Code (If same as first parent please leave blank.)
(Parent/Guardian 2)
Your answer
Emergency Contact Information
Please list the name and phone number of a close relative or family friend that can be contacted in the event you (parent/guardian) are unavailable.
Name (1st Contact)
First and Last Name
Your answer
Phone Number
Your answer
Relationship
Your answer
Name (2nd Contact)
First and Last name
Your answer
Phone
Your answer
Relationship
Your answer
Insurance Information
Do you have medical insurance? *
Required
Name of Insurance Carrier, if none type none. *
Your answer
Insurance Policy Number, if none, type none. *
Your answer
Insurance Policy Holder's Name, if none type none. *
Insurance Policy Holder's Name/If none type none.
Your answer
VHSL Eligibility
Grade for 2018-2019 *
In the past 12 months have you attended a high school other than Charlottesville High School. *
Are you currently living in Charlottesville High School District? *
Consent, Assumption of Risk, Concussion Education
Medical Consent *
By typing my name (Parent/Guardian) in the box below, I give permission to any administrator, coach, athletic trainer or other personnel of Charlottesville City Schools (CCS), or any team physician associated with CCS to seek medical treatment for my child/ward in the event of an emergency. I also understand that any financial costs due to medical treatment outside of CCS personnel is my full responsibility. I also authorize CCS to release medical information to team physicians or the student’s personal health care provider, information concerning illness or injury relative to my past, present, or future participation in athletics at CCS. I also authorize any medical facility, physician, or medical personnel to disclose to CCS any and all medical information that may be pertinent to my child/ward’s involvement in athletics at CCS.
Your answer
Assumption of Risk *
I acknowledge and accept the risks inherent in the sport in which my child/ward will participate, as well as the travel involved, and with this knowledge in mind, grant permission for my child/ward to participate in the sport and travel with the team.
Concussion Education *
Athlete and Parent have attended a current year concussion education or have reviewed the online information, and understand the information. If you have any question about concussions, treatment for concussion, return to academics or return to play protocol, you should contact the athletic trainer at CHS for further explanation. Please follow this link for concussion information. http://prezi.com/jvdy5wtmya2j/?utm_campaign=share&utm_medium=copy&rc=ex0share
Sportsmanship *
Charlottesville High School is committed to promoting good sportsmanship by student athletes, coaches, and spectators. We encourage all persons involved in athletic events to exhibit respect, fairness, integrity and responsibility before, during and after all athletic contest. Fans are encouraged to support our athletes enthusiastically without verbal abuse of opponents, officials or other spectators.
EQUIPMENT POLICY *
Student athlete and parent understand that any school issued uniform and equipment should be returned to the coach at the conclusion of the season. Student-athlete and parent/guardian will be responsible for any lost, missing or damaged equipment up to 100% replacement value.
As the parent or guardian of a Charlottesville High School student-athlete *
I understand that the my child/ward may be photographed by members of the local media for the newspaper and the local news. I am acknowledging that I give permission for my student-athlete's image to appear on the news and on the athletic website.
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