Winter Sports Registration 2023

Select the Sport for which you are registering

Registration is available for the upcoming season only
Student Information
Name Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Grade
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Student Cell Phone Student Cell Phone - ### - ### ####
Home Phone Home Phone - ### - ### ####
Family Physician
Physician Phone Physician Phone - ### - ### ####
Allergies/Medical Conditions

Please list all allergies and/or medical conditions.
Medications

Please list all medications currently being taken by the athlete.
MIAA Recommended Sports Candidate Medical Form

This form must be downloaded, printed and completed by the student's physician. The completed form must be returned BEFORE the student can participate in any athletic activities (including practice).
Acknowledge Medical Form Receipt

Acknowledge Medical Form Receipt I have downloaded the above medical form to be filled out by the student's physician and will return it completed prior to student participation.
Student Signature

As a student at NDA, I agree to fulfill my responsibilities as an athlete as outlined in all NDA documents.
Student Signature Date Student Signature Date / MM / DD YYYY
Parent/Guardian Permission and Contact Information

By nature, participation in interscholastic athletics includes risk of injury which may range in severity from minor to disabling to even death. Although serious injuries are not common in supervised school athletic programs, it is impossible to eliminate the risk. Participants can, and have the responsibility to, help reduce the chance of injury. Participants must obey all safety rules, report all physical problems to their coaches, follow a proper conditioning program and inspect their own equipment daily.

PARENTS OR STUDENTS WHO DO NOT WISH TO ACCEPT THE RISKS DESCRIBED IN THESE WARNINGS SHOULD NOT SIGN THIS PERMISSION FORM.

I hereby give permission for the above-named student,
- to represent the Academy of Notre Dame in all practices and competitions.
- to accompany the team of which she is a member on its trips to competitions.
- to receive, through an athletic trainer or medical doctor, emergency medical care which may become reasonably necessary in the course of such athletic activities and travel.

In consideration of my student's participation in interscholastic athletics, I hereby release, save harmless and indemnify the Academy of Notre Dame, its employees and agents from any and all liability for any and all injury sustained by the above-named student in the proper course of such athletic activities or travel.
Parent/Guardian Name Parent/Guardian Name First Last
Parent/Guardian Email

Confirmation of athletic registration will be sent to this address.
Cell Phone, or best number to reach in an emergency Cell Phone, or best number to reach in an emergency - ### - ### ####
Home Phone Number Home Phone Number - ### - ### ####
Work Phone Number Work Phone Number - ### - ### ####
Other Emergency Contact Name Other Emergency Contact Name First Last
Emergency Contact Phone Number Emergency Contact Phone Number - ### - ### ####
If I cannot be reached in an emergency:

If I cannot be reached in an emergency: I hereby consent for a qualified physician to examine, diagnose, and provide treatment including surgery deemed advisable for this student.
By signing this permission form, I acknowledge:

By signing this permission form, I acknowledge: I have read all of the above information and accept the risks inherent in my student’s participation in interscholastic athletics.
Parent/Guardian Signature Parent/Guardian Signature First Last
Date of Signature Date of Signature / MM / DD YYYY
Injury/Concussion Information for Extracurricular Activities

Training Fact Sheet for Parents Training Fact Sheet for Athletes
.......
Concussion Protocol Concussion Report Form
Has student ever experienced a traumatic head injury (a blow to the head)?

Has student ever experienced a traumatic head injury (a blow to the head)? Yes No
Was student ever diagnosed with a concussion?

Was student ever diagnosed with a concussion? Yes No
Statement Acknowledging Receipt of Education and Responsibility to report any signs and/or symptoms of a Concussion:
I hereby acknowledge that:

I hereby acknowledge that: I have received education about the signs, symptoms and risk of sports related concussions.
I also acknowledge:

I also acknowledge: It is my responsibility to report to the school Athletic Director, Athletic Trainer, Coaches, and School Nurse any signs/symptoms of a concussion.
Information on Opioid Misuse Prevention:

Preventing Opioid Misuse Among Student Athletes
I hereby acknowledge that:

I hereby acknowledge that: I have received education about the prevention of opioid abuse in student athletes.
Parent/Guardian Signature - Concussion and Opioid Information Parent/Guardian Signature - Concussion and Opioid Information First Last
Parent/Guardian Signature Date Parent/Guardian Signature Date / MM / DD YYYY
Student Signature - Concussion and Opioid Information Student Signature - Concussion and Opioid Information First Last
Student Signature Date Student Signature Date / MM / DD YYYY

Training Fact Sheet for Parents		Training Fact Sheet for Athletes
	.......
Concussion Protocol		Concussion Report Form

Winter Sports Registration 2023

Winter Sports Registration 2023

Student Information

MIAA Recommended Sports Candidate Medical Form

Parent/Guardian Permission and Contact Information

Injury/Concussion Information for Extracurricular Activities

Statement Acknowledging Receipt of Education and Responsibility to report any signs and/or symptoms of a Concussion:

Information on Opioid Misuse Prevention: