Athlete Information Form 2024-25

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

Student Information

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

Date of Birth*

Answer required for "Date of Birth"

Grade*

Answer required for "Grade"

Gender*

Answer required for "Gender"

Male

Female

Fall Sports you intend to participate in:

Answer required for "Fall Sports you intend to participate in: "

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 for "Winter Sports you intend to participate in:"

Girls Basketball

Varsity Boys Basketball

Junior Varsity Boys Basketball

Indoor Track (Co-Ed)

Spring Sports you intend to participate in:

Answer required for "Spring Sports you intend to participate in:"

Baseball (Boys Grade 7 and Older)

Girls Softball

Track & Field (Co-Ed)

Esports (Co-Ed)

Parent/Guardian Information

Name

Answer required for "Name"

Answer required for "Email"

Day Phone

Answer required for "Day Phone"

Night Phone

Answer required for "Night Phone"

Emergency Contact

Name

Answer required for "Name"

Relationship

Answer required for "Relationship"

Phone

Answer required for "Phone"

Medical Information

Family Physician

Physician Name

Answer required for "Physician Name"

Physician Phone

Answer required for "Physician Phone"

Family Dentist

Dentist Name

Answer required for "Dentist Name"

Dentist Phone

Answer required for "Dentist Phone"

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 for "Name of Private Insurance Carrier"

Policy Number

Answer required for "Policy Number"

Address

Answer required for "Address"

Did you purchase Student Accident Insurance?

Answer required for "Did you purchase Student Accident Insurance?"

Yes

If YES, please indicate the coverage type

Answer required for "If YES, please indicate the coverage type"

School Time

24 Hour Plan

Dental

Injury/Concussion

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

Answer required for "Has student ever experienced a traumatic head injury (a blow to the head)?"

Yes

If YES, when (Approximately)?

Answer required for "If YES, when (Approximately)?"

Has student ever received medical attention for a head injury?

Answer required for "Has student ever received medical attention for a head injury?"

Yes

If YES, when (Approximately)?

Answer required for "If YES, when (Approximately)?"

If YES, please describe the circumstances

Answer required for "If YES, please describe the circumstances"

If YES, was student diagnosed with a concussion?

Answer required for "If YES, was student diagnosed with a concussion?"

Yes

Has student had a baseline test?

Answer required for "Has student had a baseline test?"

Yes

If YES, please indicate the date of the baseline test

Answer required for "If YES, please indicate the date of the baseline test"

South Shore
Christian AcademyFor Christ. For Others.

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Athlete Information Form 2024-25