Athlete Information Form 2023-24

Please complete the form below. Required fields marked with an asterisk *

Student Information

First Name*

Answer Required

Last Name*

Answer Required

Date of Birth*

Answer Required

Grade*

Answer Required

Gender*

Answer Required

Male

Female

Fall Sports you intend to participate in:

Answer Required

Girls Soccer

Varsity Boys Soccer

Junior Varsity Boys Soccer

Girls Volleyball

Cross Country (Co-Ed)

Esports (Co-Ed)

Winter Sports you intend to participate in:

Answer Required

Girls Basketball

Varsity Boys Basketball

Junior Varsity Boys Basketball

Indoor Track (Co-Ed)

Spring Sports you intend to participate in:

Answer Required

Baseball (Boys Grade 7 and Older)

Girls Softball

Track & Field (Co-Ed)

Esports (Co-Ed)

Parent/Guardian Information

Name

Answer Required

Day Phone

Answer Required

Night Phone

Answer Required

Emergency Contact

Name

Answer Required

Relationship

Answer Required

Phone

Answer Required

Medical Information

Family Physician

Physician Name

Answer Required

Physician Phone

Answer Required

Family Dentist

Dentist Name

Answer Required

Dentist Phone

Answer Required

Insurance Information

Although we are always greatly concerned about the safety and quality of our programs, occasionally, a student athelete will be injured and require medical attention. For this reason, all students participating in athletics MUST carry insurance. Please make sure to include the policy number below.

Name of Private Insurance Carrier

Answer Required

Policy Number

Answer Required

Address

Answer Required

Did you purchase Student Accident Insurance?

Answer Required

Yes

If YES, please indicate the coverage type

Answer Required

School Time

24 Hour Plan

Dental

Injury/Concussion

Has student ever experienced a traumatic head injury (a blow to the head)?

Answer Required

Yes

If YES, when (Approximately)?

Answer Required

Has student ever received medical attention for a head injury?

Answer Required

Yes

If YES, when (Approximately)?

Answer Required

If YES, please describe the circumstances

Answer Required

If YES, was student diagnosed with a concussion?

Answer Required

Yes

Has student had a baseline test?

Answer Required

Yes

If YES, please indicate the date of the baseline test

Answer Required

South Shore
Christian AcademyFor Christ. For Others.

Please fix the highlighted areas below before submitting.

Athlete Information Form 2023-24