ATHLETIC PARTICIPATION/ EMERGENCY

FORM

Student Name____________________________________________________________

Student Address__________________________________________________________

Parent/Legal Guardian Name________________________________________________

Address (if different from above)_____________________________________________

Home Phone Number_________________ Work Phone Number__________________

Cell/Pager Number___________________ Work Phone Number __________________

Email Address____________________________________________________________

Emergency Contact Name__________________________________________________

Emergency Contact Phone_____________ Relationship to Student_________________

Family Doctor Name_________________ Phone______________________________

Hospital Preference________________________________Phone Number___________

The Diocese of Rockford mandates that all students participating in organized sports
must provide proof of insurance coverage before they begin practice.

Insurance Company Name______________________ Policy Number_______________

List allergies or health concerns/problems that you feel your coach should be aware of:

List/explain any medication taken by your child:

- OVER-
 AUTHORIZATION TO TREAT

If you and the doctor of your choice, as indicated above, cannot be reached in an
emergency, and if in the judgment of school authorities immediate medical and/or
hospital attention is indicated, do you authorize school authorities to send your child,
properly accompanied, to an available hospital or physician?

Yes_____ No_____

As a parent and/or legal guardian, I authorize the treatment of my minor child/ren by a

qualified and licensed medical doctor in the event of a medical emergency which, in the
opinion of the attending physician, may endanger his/her life, cause physical disability or
undue discomfort if delayed. This consent is granted only after a reasonable effort has
been made to reach me.

Yes_____ No_____

We, the parents/guardians of ___________________________________, hereby give

our consent and agree to release, indemnify and hold harmless the ROCKFORD
DIOCESE, its officials, coaches and representatives from any claim arising out of injury
to the above named individual. We also hold harmless the ROCKFORD DIOCESE from
any claim arising out of injuries or conditions caused by refusal to obtain medical
treatment.

Signature _______________________________________

Date _______________________________________

_____ Yes, I am interested in coaching.

Parent Name: ______________________________ (please print)

For Athletic Office Use Only:

Athletic Fee _____
Uniform Deposit _____
Participation Form/
with Medical Info. _____
Sports Physical _____
Uniform Returned _____