Development Program

Development Series Registration

Series One - Ages 12 and Under
PLAYER INFORMATION
Player's Name

First NameMiddle NameLast Name
Type a question
Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Grade in School
High School Graduation Year
T-Shirt Size
PARENT INFORMATION
Primary Contact: Parent or Guardian

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2nd Contact: Parent or Guardian

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / 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:
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
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent's Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I authorize medical treatment if my daughter becomes ill or injured
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
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I do not authorize you to abtain emergency medical/dental care for my daughter.
Parent/Guardian Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
PARENT & ATHLETE CONCUSSION AGREEMENT

Related to Concussion Law 2011 - Wisconsin Act 172
Parent/Guardian Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Player Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I Participate in: (Check all that apply)

Other
Have you ever had a concussion?
How Many?
Have you ever experienced concussion symptoms?
Did you report them?
Dates:

3/27/22
4/3/22
4/10/22
4/24/22
5/15/22
5/22/22
prevnext( X )
Group One - 12:30pm - 1:30pm$150.00
3rd-6th Graders

Group Two - 1:45pm - 2:45pm$150.00
3rd-6th Graders

Total $0.00
Should be Empty:

Development Series Registration

PLAYER INFORMATION

PARENT INFORMATION

PLAYER MEDICAL INFORMATION

PARENT & ATHLETE CONCUSSION AGREEMENT

*