Quimby Oak After School Sports Registration

Dear Parents/Guardians,

For any student to participate in the Quimby Oak Middle School After School Sports Program, you must complete and submit the information requested below. Since the possibility of injury is present in even the mildest of athletic events, some form of accident or health insurance is required before any student will be allowed to participate in any sport. There is a space provided below for you to indicate the type of insurance you carry. There is also insurance coverage available by an outside carrier made available through the school district. Your son or daughter may not participate in our After School Sports Program without insurance coverage.

If you have questions about the Quimby After School Sports program, please contact our Athletic Directors: Ms. Colleen Boyle and Mr. Jonathan Lam.
Student Participation Information
Student First Name *
Student Last Name *
Student ID#*
Student Grade*

7th Grade8th Grade
Student Email (Please no eesd.org email)*

Confirmation Email
Student Mobile Number*
Sport Registering For: *
Parent Contact Information
Parent #1 Name*

First NameLast Name
Parent#1 Mobile Number*
Parent #1 Email*

Confirmation Email
Add 2nd parent info?

YesNo
Parent #2 Name*

First NameLast Name
Parent#2 Mobile Number
Parent #2 Email*

Confirmation Email
Medical and Insurance Information
Medical Condition - Please briefly describe your child's medical condition. If they do not have a condition, please state None. *
My child is covered by health insurance*

YesNo
Family insurance carrier name: *
Impact of clicking No Health Insurance Coverage*
Subscriber's name on insurance card *
Insurance Card Group Number *
Emergency Information
Please provide two emergency contacts in case we are unable to contact

Parent #1 or Parent #2:
Emergency Contact #1*

First NameLast Name
Emergency #1 Phone #*
Emergency Contact #2*

First NameLast Name
Emergency #2 Phone #*
In case of an emergency and the parents or emergency contacts cannot be reached, I authorize school personnel to take any action deemed necessary.*

YesNo
Clicking "No" to school personnel authorization for emergencies*
Communication
Open Gym days and times are posted on our school website at quimbyoak.eesd.org under Athletics on the blue menu bar. Select the Open Gym tab to view the schedule or add it to your personal calendar.

Throughout the season there may be changes in this scheudule. The best way for us to text or email you is through the information you have listed in your Powerschool account. Please make sure all your contact information is correct in Powerschool so you can receive last minute notifications.
I have verified my Powerschool account has my current mobile phone and email information.*

YesNo
Please use my mobile and email to alert me of any changes to the sports schedule or event details.*

YesNo
By selecting "No" to the use of your mobile or email to alert you of any sports events details:*
Publicity and Social Media
I give Quimby Oak and Evergreen School District permission to use photos and videos of my child for communication and publicity purposes on their school website, social media accounts and newsletter.*

YesNo
By not allowing your student's picture to be viewed in a public forum for school:*
Agreement and Signed Consent

Document Name	Read
Quimby Oak Sports Contract	Read Document
Concussion Info Sheet	Read Document
Sudden Cardiac Arrest Info Sheet	Read Document

(Check here to indicate that you have read and agree to the terms of the Quimby Oak Sports Contract) *
(Check here to indicate that you have read and agree to the terms of the Concussion Info Sheet)*
(Check here to indicate that you have read and agree to the terms of the Sudden Cardiac Arrest Info Sheet) *
Guardian E-Signature*
Type your full name to e-sign. NOTE: E-signature must match a guardian's name*
Student E-Signature*
Type your full name to e-sign. NOTE: E-signature must match athlete's legal name*
Should be Empty:

Student Participation Information

Parent Contact Information

Medical and Insurance Information

Emergency Information

Communication

Agreement and Signed Consent