I AM VB Tryouts Registration Form

I AM Volleyball Tryout Registration

Ages 14 and Under
PLAYER INFORMATION
Player's Name *

First Name Middle Name Last Name
Male or Female *

Male Female N/A
Birthday *

Month Day Year
Date
Age *
Grade in School *
High School Graduation Year *
What team(s) are you open to play on? *

Red (1's team) Black (2's team) White (3's team)
T-Shirt Size (Deadline has passed)
Preferred Volleyball Position:
PARENT INFORMATION
Primary Contact: Parent or Guardian *

First Name Last Name
Phone Number *

Area Code Phone Number
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Secondary Contact: Parent or Guardian

First Name Last Name
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
PLAYER MEDICAL INFORMATION
Primary Insurance Company
Primary Group/Policy#
Family Physician Name:
Physician Phone:
Please elaborate on any medical conditions of which we should be aware:
Please list any medications currently being taken:
In the past 24 months, have you been tested, diagnosed and/or treated for a concussion: *

yes no
Please provide the date (Months and Year), who performed the testing/diagnosing/treatment and what was the outcome:
Please list any allergies: *
Child's Signature *

Clear
Today's Date *

Month Day Year
Date
*
Parent's Signature *

Clear
Today's Date *

Month Day Year
Date
I authorize medical treatment if my daughter becomes ill or injured *

yes no
If, during the course of my daughter's activities in volleyball, she should become ill or sustain an injury, I hereby authorize you to abtain emergency medical/dental care. I will assume financial responsibility for the bills incurred through my insurance company.
Parent/Guardian Signature

Clear
Today's Date

Month Day Year
Date
I do not authorize you to abtain emergency medical/dental care for my daughter.
Parent/Guardian Signature

Clear
Today's Date

Month Day Year
Date
PARENT & ATHLETE CONCUSSION AGREEMENT

Related to Concussion Law 2011 - Wisconsin Act 172
*
Parent/Guardian Signature *

Clear
Today's Date *

Month Day Year
Date
*
Player Signature *

Clear
Today's Date *

Month Day Year
Date
I Participate in: (Check all that apply) *

Football Track & Field Soccer Gymnastics Baseball/Softball Golf Cross Country Tennis Basketball Volleyball Cheerleading Swimming/Diving Hockey Wrestling Skiing/Snowboarding
Have you ever had a concussion? *

Yes No
How Many?
Have you ever experienced concussion symptoms? *

Yes No
Did you report them?

Yes No
Choose your tryout time *

10's and 11's (Saturday 10:30-12pm) 12's (Saturday 12-2pm) 14's (Saturday 2-3:30pm) 14's (Saturday 3:30-5pm) 13's (Sunday 3:30-5pm)
*
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Tryout Fee $ 30.00

10's Tryout Fee Free

Total $ 0.00
Should be Empty:

I AM Volleyball Tryout Registration

PLAYER INFORMATION

PARENT INFORMATION

PLAYER MEDICAL INFORMATION

PARENT & ATHLETE CONCUSSION AGREEMENT