Athletics Registration

Athletics Registration
Athlete Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Grade
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Last WIAA Physical

MonthDayYear
2 digit month, 2 digit day, 4 digit yearCheck option below if never had a WIAA physical
No Physical
The next Physical is Due:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearValue is calulcated from above using April 1st as a cutoff date
old-Date of Last WIAA Physical

MonthDayYear
2 digit month, 2 digit day, 4 digit year
today

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Days until due:
Last year
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 within the next 12 months - ({theNext})

Please Read

Athletic physicals are valid for two years.

A medical form will be emailed to you after you complete this registration. Please take this form to your healthcare provider when your athlete receives their physical.

If your athlete's physical expires during a sports season, they may complete that season. However, a new physical must be on file before they are eligible to participate in their next sports season.
Athlete is next due for a physical {theNext}

Athletic physicals are valid for two years.
Cur Year Due Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearNeed to update this every year to August 1st of year
Contact and Insurance Information
Parent/Guardian

First NameLast Name
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent's Place of Employement
Subscriber Member Name (primary Insured)
Insurance Provider
Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Policy Number
Is plan an HMO?
HMO: What is your primary care facility?
Alternate Emergency Contact

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship
Grandpa, Mom, Aunt
Address

Street Address

Street Address Line 2

CityState

Zip Code
In case of emergency:
First, Try:
Then, Try:
Primary Provider Physician
Primary Provider Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Family Dentist
Current Medications
Allergies
List allergies and severity
Immunizations up to date?
Please specify
eg., tetanus/diphtheria; measles, mpums, rubella; hepatitis A, B; influenza; polio; pneumococcal; menigococcal; varicella
Other information or medical conditions
(Medication, etc)
MEDICAL CONSENT TO TREAT STUDENT: Consent may be required in order for Student to participate in an athletic program. Consent is effective until it is
revoked by a parent or guardian, or until Student is no longer enrolled at the School.

If no box is checked, it is assumed that consent is NOT given. Please check all applicable.
If the AAH Staff (defined below) determines that Student is in need of immediate medical attention beyond that which can be provided by the AAH Staff at School (and, if a minor, the Student’s parent,guardian, or emergency contact cannot be reached) the AAH Staff may use their judgment in securing medical aid, including ambulance service and admittance to a hospital if needed.
The Advocate Aurora Health, Inc. athletic staff, including athletic trainers, coaches, or other qualified personnel (“AAH Staff”) may apply first aid treatment for any injury sustained during participation in athletic programs sanctioned by School; AAH Staff may evaluate and treat other emergent or non-emergent Student injuries or medical conditions, including concussion baseline testing, brought to AAH Staff’s attention as they relate to the Student’s physical activity, conditioning or injury prevention, regardless of whether or not the Student participates in athletics.
If available at School, AAH Staff may provide appropriate treatment modalities, such as ultrasound and electronic stimulations to treat any Student injury or other medical condition.
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
Should be Empty:

Athletics Registration

Athlete is due for a physical within the next 12 months - ({theNext})

Please Read

Athlete is next due for a physical {theNext}

Athletic physicals are valid for two years.

Contact and Insurance Information

Concussion and Sudden Cardiac Arrest Information