2017 Fall Athletic Participation Form
This form provides the athletic department, coaches and trainer with all the information needed for the Fall sports season. It must be completed prior to the first day of practice.

**All athletes must have a WIAA Physical Form on file in the athletic office showing a physician's signature for an examination after April 1, 2016.

Athlete Last Name
Your answer
Athlete First Name
Your answer
Sport
Student's School Email
Please INCLUDE the FULL email with "@stu.waukesha.k12.wi.us"
Your answer
Graduation Year
Date of Birth
MM
/
DD
/
YYYY
Parent/Guardian Information:
Student lives with:
PRIMARY CONTACT Name
Your answer
Relationship to student:
Your answer
Email Address
Your answer
Current Address
Your answer
City
Your answer
Zip Code
Your answer
Most accessible phone number
Your answer
Employer
Your answer
Work Phone
Your answer
Work Hours
Your answer
SECONDARY Contact Name
Your answer
Relationship to student:
Your answer
Email Address
Your answer
Current Address
Your answer
City
Your answer
Zip Code
Your answer
Most accessible phone number
Your answer
Employer
Your answer
Work Phone
Your answer
Work Hours
Your answer
Emergency Contacts
If my child becomes ill or injured at school and I cannot be reached, we have made arrangements with the following local friends or relatives:
Contact #1 Name:
Additional contact person, not included above
Your answer
Contact #1 Phone:
Your answer
Contact #1 Relationship to Student:
Your answer
Contact #2 Name:
Your answer
Contact #2 Phone:
Your answer
Contact #2 Relationship to Student:
Your answer
Contact #3 Name:
Your answer
Contact #3 Phone:
Your answer
Contact #3 Relationship to Student:
Your answer
Health Information for Coaches and Trainers
Please enter the up-to-date contact and medical information for Waukesha North Coaches and Trainers
Physician name and phone number
Your answer
Dentist name and phone number
Your answer
Date of Last Physical Exam
A WIAA physical card with this date of physical and the physician's signature must be on file in the athletic office. This date must be after April 1, 2016 to be valid for the 2017-18 school year.
MM
/
DD
/
YYYY
Does the athlete have significant health concerns?
Required
Please use this space to explain health concerns listed above:
If none, please enter "none."
Your answer
If Inhaler is required for asthma, please enter "yes." Also, enter location where Inhaler will be kept during practice and competition.
If none, please enter "none."
Your answer
Does the athlete have allergies?
Please list FOOD allergies, reactions and date of last reaction
If none, please enter "none."
Your answer
Please list MEDICATION allergies, reactions and date of last reaction
If none, please enter "none."
Your answer
Please list LATEX allergies, reactions and date of last reaction
If none, please enter "none."
Your answer
Please list OTHER allergies, reactions and date of last reaction
If none, please enter "none."
Your answer
Please add any other health information you feel would be important for your athlete's coaches and trainer
If none, please enter "none."
Your answer
Medication
Does your athlete take any daily medications?
Required
Medication
Does your athlete take medications at school? If yes, obtain Medication Authorization from office
Required
Please list all medications (If none, please enter "none."):
Name, Form, Time taken and Reason
Your answer
Insurance Company my child is adequately covered by
Your answer
Insurance Carrier Telephone
Your answer
Insurance Primary Subscriber Member Name
Your answer
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