REGISTRATION FORM
PHYSICIAN’S CERTIFICATE
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 19____________ - 19_______________.
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) _________________________________________________________________________
HOME WORK
ADDRESS _____________________________________________ PHONE__________________ PHONE_________________
FATHER’S SS#_________________________________________ MOTHER’S SS#___________________________________
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.
