I hereby certify that _________________________________________ (NAME OF ATHLETE) has been examined by me and found physically fit to engage in all Diocesan interscholastic athletics for the school year 20_______________ - 20_______________ PHYSICIAN'S SIGNATURE___________________________________________________ DATE_____________ _______________ GENERAL INFORMATION: NAME OF ATHLETE________________________________________________________________ SEX: M___________ F_________ ADDRESS__________________________________________________________________ PHONE___________________________ GRADE _________ AGE _________DATE OF BIRTH ____________________SS#________________________________________ PARENT(S)/LEGAL GUARDIAN(S)______________________________________________________ ________________________ ADDRESS _____________________________________________ PHONE(H)_________________ PHONE(W)_________________ ANOTHER PERSON TO CONTACT________________________________________________ _____________________________ RELATIONSHIP ___________________________________________ PHONE # ________________________________________ ALLERGIES AND OTHER MEDICAL CONCERNS _____________________________________________ ___________________ ____________________________________________________________________________________________________________ MEDICAL INSURANCE: NAME OF INSURANCE COMPANY _________________________________________________________ ____________________ POLICY NUMBER _______________________________________ GROUP NUMBER_____________________________________ ELIGIBILITY - CCD STUDENTS This student is an active member of ______________________________________________________________________________ (NAME OF PARISH) CCD Program. He/She will be participating all year in the CCD Program. __________ _________________________________________________________________________________________________ (signature of pastor or designee) ( date) PARENT CONSENT STATEMENT By signing this form, I _________________________________________________ (NAME OF PARENT/GUARDIAN) certify that I request and give my permission for _________________________________________________ (NAME OF CHILD) to engage in the Diocesan interscholastic athletic program. I release the participating schools, principals, coaches, Knights of Columbus, the Diocese of Nashville and their representatives from any and all liability and waive claims against them. __ __________________________________________________________________________________________________________ (signature of parent or legal guardian) (date) NOTE TO PRINCIPALS AND COACHES: COACHES MUST HAVE A COPY OF THIS FORM FOR EACH ATHLETE AND SHOULD KEEP IT ON HAND FOR ALL GAMES AND PRACTICES. A COPY OF THIS FORM FOR EACH ATHLETE MUST BE ON FILE IN THE PRINCIPAL'S OFFICE BEFORE HE/SHE CAN PARTICIPATE IN ANY FORM OF THE DIOCESAN INTERSCHOLASTIC PROGRAM |
| DIOCESAN ATHLETIC INTERSCHOLASTIC PROGRAM - REGISTRATION FORM PHYSICIAN'S CERTIFICATE |