Interscholastic Athletic Program Registration
Dear Parent/Guardian,
Your daughter/son would like to sign-up to participate in the
Suffield Middle School’s Interscholastic Athletic
Program. This activity involves after school time,
effort, and possible risk of injury. Students are
expected to adhere to all school policies as well as the
rules set forth by the coach. In addition, she/he will
be responsible for school-issued equipment and must
travel with the team to and from games. Family
support and understanding will help the athlete meet
these commitments.

Before the first practice, each athlete must submit
proof of a medical examination to the school nurse
(dated within the past 13 months). Annual exams are
required and certify that the student is physically fit to
participate.

Very truly yours,
Mike Bosworth
Athletic Director

UPDATED PHYSICAL REQUIRED **Non-compliance notification will go out the day before practice begins** Before the first practice, each athlete must submit proof of a medical examination to the school nurse (dated within the past 13 months). Annual exams are required and certify that the student is physically fit to participate. This is a CT Interscholastic Athletic Conference rule. *
0. ATHLETE'S YEAR OF GRADUATION *
00. Gender *
What sport are you registering for? (Please register for the sport that is "in season" only.) *
1. ATHLETE'S FIRST NAME *
Your answer
2. ATHLETE'S LAST NAME *
Your answer
3. PARENT / GUARDIAN #1 FIRST and LAST NAME *
Your answer
4. PARENT / GUARDIAN #1 EMAIL *
Your answer
5. PARENT / GUARDIAN # 1 PHONE # *
Your answer
6. PARENT / GUARDIAN #2 FIRST and LAST NAME
Your answer
7. PARENT / GUARDIAN #2 EMAIL
Use this area for a SECOND email address - adding the same email address will result in double emails.
Your answer
8. PARENT / GUARDIAN #2 PHONE #
Your answer
9. ATHLETE'S ADDRESS *
Your answer
10. FAMILY DOCTOR'S NAME *
Your answer
11. FAMILY DOCTOR'S PHONE # *
Your answer
12. FAMILY DENTIST'S NAME *
Your answer
13. FAMILY DENTIST'S PHONE # *
Your answer
14. HOSPITAL OF CHOICE *
Your answer
15. HAS THE ATHLETE HAD A KIDNEY INJURY? YES NO *
Required
16. DOES THE ATHLETE HAVE A HEART CONDITION? YES NO *
Required
17. DOES THE ATHLETE HAVE DIABETES? YES NO *
Required
18. DOES THE ATHLETE HAVE ASTHMA? YES NO *
Required
19. DOES THE ATHLETE WEAR GLASSES OR CONTACTS? YES NO *
Required
20. DOES THE ATHLETE HAVE AN ALLERGY TO BEE STINGS? YES NO *
Required
21. IS THE ATHLETE ALLERGIC TO ANY MEDICATIONS / FOODS? YES or NO - IF YES, LIST MEDICATIONS / FOODS *
Your answer
22. DATE OF LAST TETANUS SHOT: If you don't know contact doctor or write "On file" *
Your answer
23. MEDICATIONS - DOES YOUR CHILD REQUIRE AN INHALER OR EPI PEN? *
Your answer
PERMISSION FOR EMERGENCY TREATMENT / MEDICAL TREATMENT In the event of an emergency requiring medical attention, I hereby grant permission to a Select Medical Athletic Training Staff member designated by Suffield High School, a physician or other hospital personnel designated by the Suffield Middle School Coaching Staff to attend my daughter / son. I expect every effort will be made to contact me in order to receive my specific authorization before any further treatment or hospitalization is under-taken. *
Required
A copy of a physical exam (dated within the past 13 months) must be on file with the school nurse. A parent / guardian will be contacted if the student athlete's physical is out of date or will be deemed out of date during the season. The athlete will not be allowed at practice or games until a valid physical is on file with the nurse. *
Required
I give my daughter/son permission to participate in the Middle School Athletic Program and they will abide by all rules and regulations. Parent digital signature: (type your first and last name) *
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Suffield Public Schools. Report Abuse - Terms of Service - Additional Terms