Player – Parent Participation Form "*" indicates required fields Step 1 of 3 33% Player and Parent DetailsAthlete Name* First MI Last Home Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneAthlete Cell PhoneAthlete Email Athlete Date of Birth* MM slash DD slash YYYY Current Grade* 3rd (Cross Country) 4th (Cross Country) 5th 6th 7th 8th 9th 10th 11th 12th Umbrella School Name*Sport and Team of Athlete's Participation*Select all that apply Football Cheer & Dance Girls Volleyball Boys Basketball Girls Basketball Baseball Softball Track & Field Cross Country Tennis Boy's Soccer Cumulative Grade Point AveragePlease provide your GPA for the most recent grading period below. You only have to complete one of the two following fields. Please note: Athletes must maintain a Grade Point Average (GPA) of 2.0 or "C" overall in order to participate in the Middle Tennessee Athletic Conference. Cumulative Grade Point Average: Jan. - Jun.Cumulative Grade Point Average: Jul. - Dec.Parent / Guardian #1 Name* First Last Parent / Guardian #1 Work Phone*Parent / Guardian #1 Cell Phone*Parent / Guardian #1 Email* Parent / Guardian #2 Name First Last Parent / Guardian #2 Work PhoneParent / Guardian #2 Cell PhoneParent / Guardian #2 Email Medical Release DetailsAs the parent/legal guardian of the athlete specified in this form, I request that in my absence the above-named player be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentist, and staff duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have no guarantee as to the results of the examination or treatment.Allergies*Please list any known allergies of this athlete, including any allergies to medicines. Enter "N/A" if no allergies to report.Other Medical Issues*Please list any other medical problems that should be noted. Enter "N/A" if no medical issues to report.Family Physician's Name* First Last Family Physician's Phone*Insurance Carrier Name*Insurance Carrier Policy#*Emergency Contact*Please provide the name of someone to be contacted in an emergency if parent/guardian is not available. First Last Emergency Contact Home Phone*Emergency Contact Work Phone*Emergency Contact Cell Phone* Signatures and ConfirmationEntering your name and initials in the questions below provides legal confirmation of your agreements to statements specified.Parent / Athlete Participation Form*I have read, agree and completed all details for the Parent / Athlete Participation Form [ View Webpage ] Yes, I Agree and Confirm Liability Release Form*I have read, agree and completed all details for the Liability Release Form [ View Webpage ] Yes, I Agree and Confirm Concussion Information Form*I have read, agree and completed all details for the Concussion Information Form [ View PDF ] Yes, I Agree and Confirm Sudden Cardiac Arrest Information*I have read, agree and completed all details for the Sudden Cardiac Arrest Information [ View PDF ] Yes, I Agree and Confirm Athlete Name (Printed)* First Last Athlete Initials*Entering your initials here is a binding agreement to this form.Parent / Guardian #1 Name (Printed)* First Last Parent / Guardian #1 Initials*Entering your initials here is a binding agreement to this form.Parent / Guardian #2 Name (Printed) First Last Parent / Guardian #2 InitialsEntering your initials here is a binding agreement to this form.PhoneThis field is for validation purposes and should be left unchanged.
