Sports Sign ups/Medical Information for 2019-2020 school year
Please fill out the following information if you are playing a Westbrook High School sport
Email address *
Westbrook High School Athletics
First Name *
Your answer
Last Name *
Your answer
Middle Initial
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Grade *
Home Address *
Your answer
Parent/Guardian Name *
Your answer
Parent/ Guardian Primary Phone *
Your answer
Parent/Guardian Secondary Phone
Your answer
Parent/Guardian Name #2
Your answer
Parent/ Guardian #2 Primary Phone
Your answer
Parent/Guardian email
Your answer
Emergency contact information (Name, Phone) *
Your answer
Insurance Carrier *
Your answer
Policy Holder *
Your answer
Policy Number *
Your answer
Group Number *
Your answer
Please list if your child has any of the following medical conditions: Heart condition, Epilepsy/Seizure, Asthma, Contacts/Glasses, Diabetes, Allergies, Dentures/Bridge, Head Injury or concussion, Surgery (medical or ortho), Hospitalized in past year, Medications, other, (leave blank if the athlete does not have any medical conditions)
Your answer
Medical history explanations (additional explanation if needed)
Your answer
THIS STUDENT ATHLETE CARRIES:
Fall sports sign up?
Winter Sports
Spring Sports
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