Pullman School District (PSD)

Athletic Registration Form 2016-17 Section I: Information

Student name (print legibly) (Last) (First) (Middle Initial)

Male Female Grade in Sept 2016: 6th

7th

8th

9th

10th

11th 12

th Date of Birth:

Address: City: Zip Code:

Mother’s name: Father’s name:

Parent e-mail: School attended last year PHS LMS Other

Are you a transfer student? Yes No

Were you under any conditions of ineligibility when you left your previous school? Yes No

Are you a foreign exchange student? Yes No

Are you being home schooled? Yes No

Section II: Sports Information

Please check the box by all the sports that you wish to participate in throughout the school year. This participation form will

also cover any school sponsored summer camps or practices. For incoming freshman, this will cover the summer preceding

and following their freshman school year.

Pullman High School (Grades 9-12)

Fall Sports Winter Sports Spring Sports

Cheerleading Basketball (Boys) Baseball

Cross Country Basketball (Girls) Golf

Football Cheerleading Soccer (Boys)

Soccer (Girls) Swimming (Boys) Softball

Swimming (Girls) Wrestling Tennis

Volleyball Track

Lincoln Middle School- (Grades 7 & 8)

1st Quarter 2nd

Quarter 3rd

Quarter 4th

Quarter

Cross Country- Boys & Girls Boys Basketball Girls Basketball Track & Field- Boys & Girls

Football Wrestling- 6th

, 7th

, & 8th

Volleyball

Intramurals- 6th

Grade

Girls Tennis- 6th

, 7th

, & 8th

Boys Basketball- 6th

gr. Girls Basketball 6th

Gr.

Volleyball- 6th

grade

Section III: Parent Permission & Student Handbook

I give my consent for my child to participate in the above sport(s). In the event of illness and/or accident, I authorize school personnel

to approve emergency medical care. I am aware I am responsible for all medical expenses incurred.

To promote mutual understanding among the parents, student/athlete, and Pullman School District, we ask you to read the Pullman

School District Athletic Handbook. My child and I have read and understand this handbook. (Handbook is available upon

registration and/or on the PSD website.)

Student-athlete signature: Date:

Parent/Guardian signature: Date:

Section IV: Insurance Information

If participants suffer illness and/or injury serious enough to require a physician’s care, they must present their coach with a

physician’s release before resuming participation.

I understand my child cannot participate in after-school athletics unless covered by the school accident coverage plan or by a personal

plan, which meets minimum coverage provisions. Please be advised that it is your responsibility to notify school administration in

the event that medical insurance coverage for your son/daughter is cancelled, dropped or terminated, etc. Your son/daughter will

be declared ineligible to practice and/or compete until new medical insurance coverage is retained.

Parent Initial here [ ]

Name of Personal Insurance Provider: _____________________________________________

Insurance Identification Number: _________________________________________________

The above insurance company covers my child and I will continue to keep it in force throughout the sports season; therefore, I do not

wish to enroll in the school coverage plan. I authorize the Athletic Director to contact my insurance company to verify coverage

limitations.

Parent Initial here [ ]

I give my consent for my child to participate in the above sport(s). In the event of illness and/or accident, I authorize school personnel

to approve emergency medical care. I am aware I am responsible for all medical expenses incurred.

I accept full responsibility for the cost of treatment for an injury, which my child may suffer while participating in the athletic

program. Please permit my student participate in athletics.

Parent Initial here [ ]

Section V: Concussion & Sudden Cardiac Arrest Information

PLEASE SIGN BELOW indicating that you have read the attached Concussion Fact Sheet and Sudden Cardiac

Arrest Fact Sheet.

PARENT SIGNATURE - I have read and understand Section 1: A Fact Sheet for PARENTS regarding

concussions and Section 3: Sudden Cardiac Arrest:

__________________________________________________ Date____________

Signature

______________________________

Print Parent Name

STUDENT SIGNATURE - I have read and understand Section 2: A Fact Sheet for Athletes regarding

concussions and Section 3: Sudden Cardiac Arrest:

___________________________________________________ Date____________

Signature

_________________________________

Print Student Name

Section VI: Athletic Participation Checklist A student-athlete is INELIGIBLE to participant in any sport until the following items are properly completed and on file in the

athletic office: (Please check off when you have completed these forms)

1. Physical examination with a physician’s signature

2. Athletic Registration Form signed by parent/guardian &

Student

3. Emergency Information form

4. Insurance information signed by a parent/guardian

5. Signature of a parent/guardian and the athlete signifying

they have read and accepted the regulations of this

handbook

6. Current ASB card

7. All fines need to be paid or cleared

8. Safety guidelines read and signed by parent/guardian and

athlete

9. Concussion and Sudden Cardiac Death information

verification

10. Current Impact/Concussion Testing

Pullman School District Athletic Department

Emergency Information Form 2016-17

Student Athlete: Grade:

Student/Parent/GuardianAddress:

City, State, Zip:

Home Phone #: Email contact

Mother’s Name: Work#: ( ) Cell #: ( )

Father’s Name: Work#: ( ) Cell #: ( )

Guardian’s Name: Work#: Cell #:

Family Physician: Phone# ( )

Emergency Contact: Phone# ( )

Preferred Hospital:

Allergies:

Medication:

Insurance Company:

Insurance ID Number:

If, in the event of serious injury, your family physician is not available or is not located in the immediate vicinity, and we are unable

to contact one or the other parent, does the coaching staff have your permission to seek medical attention for the nearest

physician? Yes No

If your answer is No, please specify the procedure you wish the coaching staff to follow.

If an emergency arises while your child is participating in a contest away from home, do you consent to an examination and/or

treatment by a physician recommended by the host school authorities?

Yes No

If your answer is No, please specify the procedure you wish the coaching staff to follow.

Signature of Parent/Legal Guardian: ________________________________Date:___________________

Permission to use Student Photos in District Publications

During your child’s time in the Pullman School District, photographs may be taken of your son/daughter. These photographs may be

used in any one of the following communications:

School website School publications Training courses Local newspapers as part of media coverage of a school event Displays Use by the Pullman School District for promotional purposes

Personal details of the students will not appear in any school publication or on the website. However, individual names may appear

in a local newspaper, if appropriate to the article.

Please sign below if you DO NOT give permission for photographs of___________________________ to be used by the

Pullman School District. (print student’s name)

Signature of Parent/Legal Guardian: _________________________ Date of Signature: ________________

KEEP THIS COPY Also available online at http://www.psd267.org/Page/466

KEEP THIS COPY Also available online at http://www.psd267.org/Page/466

KEEP THIS COPY Also available online at http://www.psd267.org/Page/466

Section 3