Athletics Registration Form

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Emergency Information, Release and Permission to Participate on a Tri-City Christian Academy Sports Team

Student Information

Name*

Answer Required

Grade*

Answer Required

Date of Birth

Answer Required

Student Email

Answer Required

Student Mobile Phone

Number Required

Parent / Guardian Contact Information

Contact Information

Parent / Guardian Name*

Answer Required

Mobile Phone*

Number Required

Email*

Answer Required

Additional Parent / Guardian Name

Answer Required

Phone Number

Number Required

Email Address

Answer Required

Emergency Contact Information

Name & Phone Number*

Answer Required

Name & Phone Number*

Answer Required

Emergency Medical Information

Student's Doctor*

Answer Required

Phone Number*

Number Required

Student's Dentist

Answer Required

Phone Number

Number Required

Please select if your child has any allergies to the follow:*

Answer Required

Medications

Foods

Insects

Latex/Other

None

Please list any allergies selected above here and provide additional information.

Answer Required

Has your child ever had an allergic reaction requiring hospital treatment or an Epipen?

Answer Required

If yes, please provide details

Answer Required

Does your child have any medical conditions or asthma?

Answer Required

If yes, please provide details

Answer Required

Medications: Please list all medications, including inhalers, prescribed to your child, as well as dosages and frequency of use:

Answer Required

Insurance Information

Insurance Company*

Answer Required

Policy #*

Answer Required

Name of Subscriber*

Answer Required

Permission to Participate and Transport to Games

I give permission for my child to participate on the TCCA athletics team. I understand that my child and I must abide by all TCCA policies and rules regarding athletics. I verify that a completed physical examination form has been submitted to TCCA.*

Answer Required

Yes

I verify that my son/daughter has been cleared by a physician to participate in sports with no restrictions.*

Answer Required

Yes

I give permission to TCCA to transport my child to and from sporting events by school van or car provided by TCCA or TCCA parents.*

Answer Required

Yes

Permission to Treat

I give permission to TCCA and its employees and/or coaches to treat minor injuries or to transport my child to the nearest medical facility via ambulance in the event of a more serious injury or illness. I understand that the TCCA employees and/or coaches will use their best judgment in treating my child. I will make every effort to be available by phone while my child participates in this sport and will provide TCCA with updated phone numbers as they change.

I also give permission to TCCA and its employees and/or coaches to give my child acetaminophen (Tylenol) or ibuprofen (Advil) should he/she require it.

Release

I/we acknowledge that participating in sports can be dangerous activities involving many risks of injury. In consideration of my child/ward being allowed to participate in competitive sports, and intending to be legally bound, I/we do hereby release and forever discharge Tri-City Chrisitan Academy (TCCA), its Board, officers, employees, coaches, agents, administrators and volunteers from any/all liabilities, claims, losses, demands, costs, expenses, or rights of action, of whatever kind or nature, which I/we have or which may hereafter accrue to me/us against TCCA, by reason of injuries sustained by my child/ward participating in sports or in transit to or from participation in sports. I/we agree, for myself/ourselves and successors, that this Agreement and Release of Liability contains the entire agreement between myself/us and TCCA and that the terms hereof are contractual and not a mere recital.

Signature*

Signature Required

Please fix the highlighted areas below before submitting.

Athletics Registration Form