Track &amp; Field Registration

Parental Information

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

I am the child's REQUIRED Please fill out this field.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Email REQUIRED Please fill out this field. Please enter an email address.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

My child has the following health insurance coverage: Private Health Insurance Health Insurance provided through St. Rita

The name of my Private Health Insurance and Policy Number is Please enter valid data.

Name of Policy Holder Please enter valid data.

Student Information

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Current Grade REQUIRED 5th Grade 6th Grade 7th Grade 8th Grade Please fill out this field.

My child is a REQUIRED Please fill out this field.

My Child has completed and turned in a sports physical within the past 12 months

Each child must have completed a sports physical within the past 12 months in order to compete in track and field

Yes No

Please list any and all medical conditions of your child that the coaches should be made aware. (If none, state none.) REQUIRED Please fill out this field. Please enter valid data.

Pediatrician's Name (If none state none). REQUIRED Please fill out this field. Please enter valid data.

Pediatrician's Phone Number REQUIRED Please fill out this field. Please enter a phone number.

EMERGENCY INFORMATION AND PERMISSION TO TREAT

Emergency contact

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Emergency Contact Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Relationship to your child REQUIRED Please fill out this field. Please enter valid data.

Permission to treat in an emergency

During athletic competition, there are situations that sometimes arise where a student/athlete may require emergency medical attention.

In the event we cannot be reached to obtain permission for medical attention, by clicking "I Agree" below, I hereby authorize St. Rita school, youth programvolunteers, and/or its authorized agent and employee representative(s) to act for me in an emergency or other circumstance requiring any medical treatment or attention on behalf of my child without any further permission. This consent and authorization shall include, but not be limited to, obtaining necessary hospital, medical, surgical, dental, optical, pharmaceutical, and any related care for my child and to sign any authorization therefore including admissions and/or discharges from any hospital or other care facility. I also agree to assume financial responsibility for all costs associated with medical treatment and/or transportation.

St. Rita staff will make every effort to reach the provided emergency contacts in the event of a medical issue. In most cases, parental permission will be obtained before providing treatment, especially in nonemergency situations

I Agree Please select this field.

COACHING

Please contact me about possibly coaching or acting as an assistant coach for track and field Yes No

Saint Rita of Cascia School

"Rejoice always, pray continually, give thanks in all circumstances;
for this is God's will for you in Christ Jesus." -1 Thessalonians 5:16-18

Track & Field Registration