PIAA Sec 1-5

Welcome to the 2022-2023 Season

By completing this registration, you will be completing the PIAA required forms for NEW ATHLETES WHO DID NOT PARTICIPATE IN A FALL 2022 SPORT.
Athlete's Name *
Select One *

Male Female
Athlete Date of Birth *

Month Day Year
Date
Age of Athlete on Last Birthday *
Grade for Current School Year *
Athlete Physical Address *
Athlete Home Phone Number *
Parent/Guardian Cell Number *
Parent/Guardian E mail Address *
example@example.com
Fall Sport(s)
Winter Sport(s)
Spring Sport(s)
Parent's/Guardian's Name *
Relationship *
Parent/Guardian Address *
Parent/Guardian Cell Number *
Secondary Emergency Contact Name
Relationship
Secondary Contact Address
Secondary Contact Phone Number
Medical Insurance Carrier *
Policy Number *
Medical Insurance Address *
Medical Insurance Phone Number *
Family Physician's Name *
Physician Address *
Physician Phone Number *
Athlete's Allergies *
Athlete's Health Condition(s) of Which an Emergency Physician or Other Medical Personnel Should be Aware
Athlete's Prescription Medications and conditions of which they are being prescribed
I hereby give my consent for
born on

Month Day Year
Date of Birth
who turned
Age on last birthday
on his/her last birthday, a student of *
Name of School
and a resident of the *
Name of Public School District
to participate in Practices, Inter-School Practices, Scrimmages, and/or Contests during the Fall 20_____ *
Enter two-digit Fall year
to Spring 20_____ *
Enter two-digit Spring year
school year in the sport(s) as indicated by my signature following the name of the said sport(s) below.
FALL SPORTS - SELECT ALL THAT APPLY

Cross Country Field Hockey Football Golf Soccer Girls' Tennis Girls' Volleyball Water Polo Other
WINTER SPORTS - SELECT ALL THAT APPLY

Basketball Bowling Competitive Spirit Squad Girls' Gymnastics Rifle Swimming and Diving Track and Field Indoor Wrestling Other
SPRING SPORTS - SELECT ALL THAT APPLY

Baseball Boys' Lacrosse Girls' Lacrosse Softball Boys' Tennis Track and Field Outdoor Boys' Volleyball Other
Parent's/Guardian's Signature regarding any sports marked above that Athlete participates in. *

Clear
Understanding of eligibility rules: I hereby acknowledge that I am familiar with the requirements of PIAA concerning the eligibility of students at PIAA member schools to participate in Inter-School Practices, Scrimmages, and/or Contests involving PIAA member schools. Such requirements, which are posted on the PIAA Web site at www.piaa.org, include, but are not necessarily limited to age, amateur status, school attendance, health, transfer from one school to another, season and out-of-season rules and regulations, semesters of attendance, seasons of sports participation, and academic performance.
Parent's/Guardian's Signature *

Clear
Date *

Month Day Year
Date
Disclosure of records needed to determine eligibility: To enable PIAA to determine whether the herein named student is eligible to participate in interscholastic athletics involving PIAA member schools, I hereby consent to the release toPIAA of any and all portions of school record files, beginning with the seventh grade. of the herein named student specifically including, without limiting the generality of the foregoing, birth and age records, name and residence address of parent(s) or guardian(s), residence address of the student, health records, academic work completed, grades received, and attendance data.
Parent's/Guardian's Signature *

Clear
Date *

Month Day Year
Date
Permission to use name, likeness, and athletic information: I consent to PIAA's use of the herein named student's name, likeness. and athletically related information in video broadcasts and re-broadcasts, webcasts and reports of Inter-School Practices, Scrimmages, and/or Contests, promotional literature of the Association, and other materials and releases related to interscholastic athletics.
Parent's/Guardian's Signature *

Clear
Date *

Month Day Year
Date
Permission to administer emergency medical care: I consent for an emergency medical care provider to administer any emergency medical care deemed advisable to the welfare of the herein named student while the student is practicing for or participating in Inter-School Practices, Scrimmages, and/or Contests. Further, this authorization permits, if reasonable efforts to contact me have been unsuccessful, physicians to hospitalize, secure appropriate consultation, to order injections, anesthesia (local, general, or both) or surgery for the herein named student. I hereby agree to pay for physicians' and/or surgeons' fees, hospital charges, and related expenses for such emergency medical care. I further give permission to the school's athletic administration, coaches and medical staff to consult with the Authorized Medical Professional who executes Section 7 regarding a medical condition or injury to the herein named student.
Parent's/Guardian's Signature *

Clear
Date *

Month Day Year
Date
Confidentiality: The information on this CIPPE shall be treated as confidential by school personnel. It may be used by the school's athletic administration, coaches and medical staff to determine athletic eligibility, to identify medical conditions and injuries, and to promote safety and injury prevention. In the event of an emergency, the information contained in this CIPPE may be shared with emergency medical personnel. Information about an injury or medical condition will not be shared with the public or media without written consent of the parent(s) or guardian(s
Parent's/Guardian's Signature *

Clear
Date *

Month Day Year
Date
I hereby acknowledge that I am familiar with the nature and risk of concussion and traumatic brain injury while participating in interscholastic athletics, including the risks associated with continuing to compete after a concussion or traumatic brain injury.
Athlete's Signature *

Clear
Date *

Month Day Year
Date
Parent's/Guardian's Signature *

Clear
Date *

Month Day Year
Date
I have reviewed this form and understand the symptoms and warning signs of SCA. have also read the information about the electrocardiogram testing and how it may help to detect hidden heart issues.
Athlete's Signature *

Clear
Print Athlete's Name *
Date *

Month Day Year
Date
Parent's/Guardian's Signature *

Clear
Print Parent/Guardian's Name *
Date *

Month Day Year
Date
We willingly agree to comply with the stated guidelines put forth by the student's school and PIAA to limit the exposure and spread of COVID-19 and other communicable diseases. We certify that the student is, to the best of our knowledge, in good physical condition and allow participation in this sport at our own risk. By signing this Supplement, we acknowledge that we have received and reviewed the student's school athletic plan.
Date *

Month Day Year
Date
Athlete's Signature *

Clear
Print Athlete's Name *
Parent's/Guardian's Signature *

Clear
Print Parent/Guardian's Name *
Should be Empty:

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Welcome to the 2022-2023 Season