Basketball Participation Agreement

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To participate in Gregory Athletics, a parent/guardian must fill out this form entirely.

Last Name of Athlete *

First Name of Athlete *

Grade *

7th Grade

8th Grade

For which sport are you participating? *

Street Address *

City *

Bolingbrook

Naperville

Zip Code *

Home Telephone *

(xxx) xxx-xxxx

Date of Birth *

xx/xx/xxxx

Parent/Guardian #1 Name *

Parent/Guardian #1 Cell Phone *

(xxx) xxx-xxxx

Email Address #1 *

Accessible during the school day

Parent/Guardian #2 Name *

Parent/Guardian #2 Cell Phone *

(xxx) xxx-xxxx

Email Address #2 (optional)

Accessible during the school day

Family Doctor's Name *

Family Doctor's Phone Number *

(xxx) xxx-xxxx

Does the athlete have a physical form on file with the school nurse? *

ALL STUDENTS TRYING OUT/PRACTICING FOR A SPORT MUST HAVE A CURRENT PHYSICAL EXAM ON FILE WITH THE SCHOOL NURSE. A CURRENT PHYSICAL EXAM IS ONE THAT HAS BEEN COMPLETED WITHIN THIRTEEN (13) MONTHS OF THE LAST DAY OF THE SEASON.

Yes

Is your athlete covered under a school insurance policy? *

Clicking “No” constitutes a waiver and a confirmation of other insurance coverage:

Yes

Personal Insurance Company

If the athlete is not covered under a school insurance policy, completing this question constitutes a waiver and a confirmation of other insurance. What is the name of your insurance company?

Insurance Policy Number

Medical Concerns *

Briefly list any medical concerns. If none, write "None".

Concussion Sign Off Form Completed and Returned to Coaches *

See Link - Print, Sign, Turn-in to coaches - https://drive.google.com/file/d/0BxDPiAvvmzl1ZXdfaTA3YWtTODA/view

Yes, I have completed the Concussion Sign Off Form

I have read and am aware of the Gregory Code of Conduct. *

See Link - Print, Sign, Turn-in to coaches - https://docs.google.com/document/d/1RCYBf8fFqnWDvs4Llh5Dd7-Ly67y2VbvG8lqWx8WIoQ/edit

Yes, I have read the code of conduct.

I approve of my child’s request to participate in the Middle School Athletic Program and also understand the statements below. *

1. Clicking the box below constitutes written permission for your child to participate in Gregory basketball. 2. Athletes are responsible for equipment issued to them. 3. Either home or school medical insurance is required. 4. While participation in athletics provides student-athletes with valuable and constructive experiences of both a social and physical nature, it must be remembered and understood normal participation in games and practices may also bring the possibility of serious injury. While every precaution is taken to safeguard athletes from injury, a certain amount of risk is inherent in athletic participation. I understand the inherent risk involved.

Yes, my child has permission to participate

Athletic Fee - $ 125 *

I understand that this amount will be posted to my PushCoin account

Name of Person (Parent/Guardian) Completing Registration *

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