Step 3: Fill Out the Registration Form - OAR Amery School District

Athletic Registration Form

Create Instructions for this form


STUDENT INFORMATION:

First Name:	*

Middle Initial:	*

Last Name:	*

Street Address:	*

City:	*

Zip:	*

Date of Birth:	*

Age:	*

Home Phone:	*

Grade for 2019-20 school yr:	*

	Select all school sports you intend to play next year
		HS Football
		HS Girls Golf
		HS Girls Tennis
		HS Cross Country
		HS Soccer
		HS Volleyball

		MS Football
		MS Volleyball
		MS Cross Country (6,7,8)

		HS Wrestling
		HS Boys Basketball
		HS Girls Basketball
		HS Boys Hockey
		HS Girls Hockey

		MS Wrestling (6,7,8)
		MS Basketball Girls
		MS Basketball Boys

		HS Track
		HS Softball
		HS Girls Soccer
		HS Boys Tennis
		HS Baseball
		HS Golf Boys

		MS Track



PARENT/GUARDIAN INFORMATION

First Name:	*

Last Name:	*

Street Address:	*

City:	*

Zip:	*

Cell Phone:	*

Email:

Please list the names and grades of other family members that are participating in athletics in the Amery School District.



AUTHORIZED PERSON TO CONTACT IN CASE OF AN EMERGENCY I.E.- Grandfather, Grandmother, family friend

First Name:	*

Last Name:	*

Relationship to Student:	*

Cell Phone:	*



PRIMARY CARE DOCTOR INFORMATION

Hospital of Choice (location of athletic event may dictate this)	*

Please list any medications student is currently taking

Please list any pre-existing conditions student currently has

PERMISSION TO SHARE INFORMATION

	* Do we have your permission for the hospital to share information with our athletic trainer and athletic office including physical clearance forms?
		Yes
		No

	* Do we have your permission for our athletic trainer to share information with your son/daughter's coach?
		Yes
		No

	* Does Sports Medicine have your permission to examine and treat your child?
		Yes
		No



	Have you every exhibited signs, symptoms or behaviors consistent with a concussion (such as loss of consciousness, headache, dizziness, confusion, or balance problems) during a sporting competition at any level?
		Yes
		No

	Have you ever been diagnosed with a concussion?
		Yes
		No

If yes to either of the above questions, please list and explain each individual circumstance (sign, symptom, or behavior, followed by date of incident)

	Do you currently have or have you ever had athletic participation restrictions in relation to being diagnosed with a concussion?
		Yes
		No



WIAA AND WISCONSIN CONCUSSION INFORMATION

Wisconsin law requires all youth athletic organizations to educate coaches, athletes and parents on the risks of concussions and head injuries and prohibits participation in a youth activity until the athlete and parent or guardian has returned a signed agreement sheet indicating they have reviewed the concussion and head injury informational materials. The law requires immediate removal of an individual from a youth athletic activity if symptoms indicate a possible concussion has been sustained. A person who has been removed from a youth athletic activity because of a determined or suspected concussion or head injury, may not participate again until he or she is evaluated by a health care provider and receives written clearance from the health care provider to return to the activity. Amery School District administers the base line ImPact concussion test. We require students to have a new baseline test every year.







Athletes: Please type your name here.	*

SIGNATURE AND AUTHORIZATION By clicking SEND on this form, you authorize that you are the legal parent of the student named in this form and that you recognize that this is your legal and binding electronic signature and that any fraud or inaccuracy will void this student's eligibility.

Send a copy of the completed form to this email address :

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