Athletics Registration

Athletics Registration
Athlete Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Grade*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Date of Last WIAA Physical

MonthDayYear
Check option below if never had a WIAA physical
This Athlete has never had a WIAA Physical
The next Physical is Due:

MonthDayYear
Value is calulcated from above using April 1st as a cutoff date
Date of Last WIAA Physical

MonthDayYear
This Athlete has never had a WIAA Physical
April 1st of Last year

MonthDayYear
SET THIS EVERY YEAR
today

MonthDayYear
This athlete needs a completed physical before playing this season
This is calculated with an April 1st cutoff date + 2 years
Athlete is due for a physical

A medical form will be emailed to you after you complete this registration.
Cur Year Due Date

MonthDayYear
Need to update this every year to August 1st of year
CALCULATOR
Insurance Information
Parent's Place of Employement*
Subscriber Member Name (primary Insured)*
Insurance Provider*
Insurance Phone Number*
Please enter a valid phone number.
Primary Provider Physician*
Family Dentist*
Allergies*

YesNo
Types?*

SeasonalPetDustLatexMedicationFoodMoldInsect
List allergies and severity*
Immunizations up to date?*

YesNo
Please specify*
eg., tetanus/diphtheria; measles, mpums, rubella; hepatitis A, B; influenza; polio; pneumococcal; menigococcal; varicella
Other information
(Medication, etc)
Concussion and Sudden Cardiac Arrest Information

https://www.wiaawi.org/Portals/0/PDF/Health/Concussion-SuddenCardiacArrest-InfoSheet2022.pdf
1. I hereby give my permission for the above named student to practice and compete and represent the school in WIAA approved interscholastic sports except those restricted on this card.

2. Pursuant to the requirements of the Health Insurance Portability and Accountability Act of 1996 and the regulations promulgated thereunder (collectively known as "HIPAA"), I authorize health care providers of the student named above, including emergency medical personnel and other similarly trained professionals that may be attending an interscholastic event or practice, to disclose/exchange essential medical information regarding the injury and treatment of this student to appropriate school district personnel such as but not limited to: Principal, Athletic Director, Athletic Trainer, Team Physician, Team Coach, Administrative Assistant to the Athletic Director and/or other professional health care providers, for purposes of treatment, emergency care and injury record-keeping.

3. It is recommended that information regarding your child's allergies and prescribed medication be made available.
4. I Also attest to the fact that the above named student has had no injury or illness serious enough to warrant a medical evaluation prior to participaitng this school year.

PARENT: If there is any question that this student may not be qualitifed for athletic competition without, at least, a partial re-evaluation, contact your medical advisor before signing card.
OHS Sports are $50 per sport ($250 max / family)

Fees should be selected and paid in Infinite Campus before you play.
Parent/Guardian Email:*
Signature

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Athletics Registration

Insurance Information

Concussion and Sudden Cardiac Arrest Information