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
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