Regents Athletics Registration Form

Regents Athletics Registration Form

Please complete and submit the following form.
Student Information
Student Name*

First NameLast Name
Student Birthdate*

MonthDayYear
Student Grade*
School*

RegentsHomeschool
Name

First NameLast Name
Sport*
Hold Ctrl (or Command) to select multiple sports.
Parent/Guardian Information
Parent/Guardian Name*

PrefixFirst NameLast Name
Phone Number*

Area CodePhone Number
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Name

PrefixFirst NameLast Name
Phone Number

Area CodePhone Number
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Medical/Emergency Information
Allergies*
Physician Name*
Physician Phone Number*

Area CodePhone Number
Preferred Hospital*

UVA Medical CenterMartha Jefferson Hospital
Complete this section to include an emergency contact different from or in addition to the parent/guardian listed above.
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
Parents and student-athletes must read the Regents Athletic handbook and return a signed copy of the Athletics Handbook Acknowledgement. Both forms can be found on the Athletics page of the Regents website or by clicking the following links:
- Athletic Handbook
- Athletics Handbook Acknowledgement
Additionally, student-athletes must have the following documents on file:
- Contact & Release Form
- Sports Physical
Once forms are completed and signed, they can be uploaded below.
Upload a File

Cancelof
Upload a File

Cancelof
Upload a File

Cancelof
Electronic Signature*

I understand that checking this box constitutes a legal signature confirming that, to the best of my knowledge, I have provided accurate information.
Should be Empty: