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

AS STATED ABOVE - AN UPDATED PHYSICAL IS REQUIRED TO BEGIN PRACTICING **Non-compliance notification will go out the day before practice begins** This means 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. *
What sport are you registering for? (Please register for a sport that is "in season" only.) *
For Cross Country 2018 - I am interested in learning about the Free Optional Summer Training being offered by Jesse Howes (volunteer instructor). If you choose YES your email will be given to Jesse and he will contact you with important details. *
Required
ATHLETE'S FIRST NAME *
Your answer
ATHLETE'S LAST NAME *
Your answer
ATHLETE'S YEAR OF GRADUATION *
GENDER *
PARENT / GUARDIAN #1 FIRST and LAST NAME *
Your answer
PARENT / GUARDIAN # 1 PHONE # *
Your answer
PARENT / GUARDIAN #1 EMAIL *
Your answer
PARENT / GUARDIAN #2 FIRST and LAST NAME
Your answer
PARENT / GUARDIAN #2 PHONE #
Your answer
PARENT / GUARDIAN #2 EMAIL
Use this area for a SECOND email address - adding the same email as Guardian #1 address may result in double emails.
Your answer
ATHLETE'S HOME ADDRESS *
Your answer
FAMILY DOCTOR'S NAME *
Your answer
FAMILY DOCTOR'S PHONE # *
Your answer
FAMILY DENTIST'S NAME *
Your answer
FAMILY DENTIST'S PHONE # *
Your answer
HOSPITAL OF CHOICE *
Your answer
HAS THE ATHLETE HAD A KIDNEY INJURY? YES NO *
Required
DOES THE ATHLETE HAVE A HEART CONDITION? YES NO *
Required
DOES THE ATHLETE HAVE DIABETES? YES NO *
Required
DOES THE ATHLETE HAVE ASTHMA? YES NO *
Required
DOES THE ATHLETE HAVE AN ALLERGY TO BEE STINGS? YES NO *
Required
MEDICATIONS - DOES THE ATHLETE REQUIRE AN INHALER OR EPI PEN? *
Required
DOES THE ATHLETE WEAR GLASSES OR CONTACTS? YES NO *
Required
IS THE ATHLETE ALLERGIC TO ANY MEDICATIONS / FOODS? YES or NO - IF YES, LIST MEDICATIONS / FOODS NEXT *
Required
IF YES, TO ABOVE - ALLERGIES TO ANY MEDICATIONS / FOODS - LIST HERE
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 attend 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
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