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 for "Name"

Grade*

Answer required for "Grade"

Date of Birth

Answer required for "Date of Birth"

Student Email

Answer required for "Student Email"

Student Mobile Phone

Number Required

Parent / Guardian Contact Information

Contact Information

Parent / Guardian Name*

Answer required for "Parent / Guardian Name"

Mobile Phone*

Number Required

Email*

Answer required for "Email"

Additional Parent / Guardian Name

Answer required for "Additional Parent / Guardian Name "

Phone Number

Number Required

Email Address

Answer required for "Email Address"

Emergency Contact Information

Name & Phone Number*

Answer required for "Name & Phone Number"

Name & Phone Number*

Answer required for "Name & Phone Number"

Emergency Medical Information

Student's Doctor*

Answer required for "Student's Doctor"

Phone Number*

Number Required

Student's Dentist

Answer required for "Student's Dentist"

Phone Number

Number Required

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

Answer required for "Please select if your child has any allergies to the follow:"

Medications

Foods

Insects

Latex/Other

None

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

Answer required for "Please list any allergies selected above here and provide additional information."

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

Answer required for "Has your child ever had an allergic reaction requiring hospital treatment or an Epipen?"

If yes, please provide details

Answer required for "If yes, please provide details"

Does your child have any medical conditions or asthma?

Answer required for "Does your child have any medical conditions or asthma?"

If yes, please provide details

Answer required for "If yes, please provide details"

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

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

Insurance Information

Insurance Company*

Answer required for "Insurance Company"

Policy #*

Answer required for " Policy #"

Name of Subscriber*

Answer required for "Name of Subscriber"

I am signing my child up for the following activities:*

Answer required for "I am signing my child up for the following activities:"

MS/HS Pickleball Monday/Wednesday - $50

MS/HS Spring Golf - Tuesdays in May - $200

MS/HS Futsol - Saturdays in May - $75

MS/HS Running Club - Tuesday/Friday - $25

K/E Fun Run Thursdays - $25

MS/HS Street Hockey - Fridays - $40

Please submit payments to the front office at either campus: ATTN Athletics/N.Clark

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 for "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."

Yes

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

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

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 for "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."

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