The Ursuline School

Fall Athletic Registration, Request to Participate and Permission Form 2022-23

This form is to be read and completed by the student athlete's parent or guardian.

Students: First Namerequired

Last Namerequired

Graderequired

Student's School email or Parent Email required

Are you Vaccinated?*

Yes No

Please be sure to upload an image of your latest Vaccination:

Attach File of Covid Vaccine

Max file size: 10 MB

Parent/Guardian: First Namerequired

Last Namerequired

Home/Cell Phonerequired

Emergency Phonerequired

Parent/Guardian Preferred Emailrequired

List a neighbor or relative who will assume temporary care if you cannot be reached: (Name/Relation and Phone# )required

I understand that injuries are possible and my daughter is covered by Medical insurance.*

Yes No

Insurance Carrier:required

Policy Numberrequired

You may choose to upload a copy of your insurance ID Card

Max file size: 10 MB

In the case of an accident or serious illness, I request the school to call 911 and then contact me. If I am unable to be reached, I give permission for any medical treatment that is necessary for the health and care of my daughter.

required*

Yes No

By checking yes above I acknowledge that I am the parent/guardian of the student athlete named on this form.

Physician's Namerequired

Physician's Phone Number/srequired

Permission for Treatment by Certified Athletic Trainer

Athletic trainers (ATCs) as defined by the National Athletic Trainers Association are “highly qualified, multi-skilled health care professionals who collaborate with physicians to provide preventative services, emergency care, clinical diagnosis, therapeutic intervention and rehabilitation of injuries and medical conditions. Athletic trainers work under the direction of a physician as prescribed by state licensure statutes. Athletic trainers are sometimes confused with personal trainers. There is, however, a large difference in the education, skillset, job duties and patients of an athletic trainer and a personal trainer. The athletic training academic curriculum and clinical training follows the medical model. Athletic trainers must graduate from an accredited baccalaureate or master’s program, and 70% of ATs have a master’s degree.”

For more information about certified athletic trainers and their roles in schools, please visit https://www.nata.org/about/athletic-training.

I hereby give permission for my daughter to be treated by the Ursuline School’s certified athletic trainer.*

Yes No

By checking yes above I acknowledge that I am the parent/guardian of the student athlete named on this form.

I understand that treatment will involve a comprehensive evaluation and possibly physical therapy and therapeutic modalities such as therapeutic ultrasound and electric stimulation. I release the Ursuline School, the treating ATC and physician from any liability.

Comments:

Participation in High Risk Sport

Participation*

I understand that having daughter compete in a high risk sport during a pandemic increases her chances of contracting any virus and have voluntarily assumed any risk of contracting any virus.

Yes No

Release of Liability

I hereby release and hold harmless The Ursuline School and any of its coaches/employees from any and all liability, from any misfortune or injury that could arise due to my daughter's participation on any athletic team.*

Yes No

By checking yes above I acknowledge that I am the parent/guardian of the student athlete named on this form.

Communication for Ursuline Athletics - SportsYou App

I give permission for my child to download, create a free account and utilize the SportsYou app solely for the purpose of Ursuline athletic mobile communication.

Permission for SportsYou App:*

Yes No

By checking yes above I acknowledge that I am the parent/guardian of the student athlete named on this form.

By filling in my name below, I acknowledge that I am the parent/guardian of the student named on this form and that the answers indicated above are mine.

Date required (mm/dd/yyyy)

Name of parent/guardian:required