Fill Out the Registration Form - OAR Algonquin Regional HS

ARHS Athletic Registration Form

Algonquin Regional High School Athletics Registration Form
Please fill this form out to register for activities.

Once team selections have been completed a $200 per student-athlete per season athletic fee must be submitted to the Athletic Office.


STUDENT INFORMATION:

First Name:	*

Last Name:	*

Date of Birth (MM/DD/YYYY):	*

Phone:	*

Street Address:	*

City:	*

Zip:	*

Email:	*

Grade for 2017-18 school yr:	*

	* Please tick off Yes if you're signing up as Manager or No if otherwise
		Yes
		No

	* Winter Sport (pick one):
		Basketball - Boys
		Basketball - Girls
		Swimming
		Skiing
		Gymnastics
		Ice Hockey- Boys
		Ice Hockey - Girls
		Indoor Track - Boys
		Indoor Track - Girls
		Winter Cheerleading
		Wrestling




PARENT/GUARDIAN INFORMATION

First Name:	*

Last Name:	*

Relationship to Student:	*

Work Phone:	*

Cell Phone:	*

Email:	*

Street Address:	*

City:	*

Zip:	*

SECONDARY CONTACT INFORMATION

First Name:	*

Last Name:	*

Relationship to Student:	*

Phone:	*

Email:

Street Address:

City:

Zip:



HEALTH INSURANCE INFORMATION

	Please check the following:
		We certify that we are providing the require school insurance for the student.
		We certify that we are not providing the school insurance as we have insurance coverage with the following:

Carrier:

Policy Holder:

Policy #:

Name of Primary Care Physician:

Primary Care Physician's Phone #:

Health Insurance Company and ID/Policy #	*



Date of Last Physical (must send in a hardcopy to the ARHS Athletic Department)	*



MEDICAL QUESTIONNAIRE

	Health Issues (check all that apply):
		Asthma and /or Allergies	Fainting and /or Convulsions
		Rheumatic Fever	Kidney Disease/Injury
		Heat Stroke/ Heat Exhaustion	Diabetes
		Menstrual Disorders	Blood Disorders
		Mononucleosis	Hepatitis
		Bronchitis	Head Injury
		Concussion	Seizure
		Tumors

If yes to any above, please explain

	* 1. Do you know of any disease and/or ailment that could impact your son/daughter's ability to participate in sports? If so, please provide an explanation. The District may require a recommendation from the child's physician regarding this matter.
		Yes
		No

Explain:

	* 2. To the best of your knowledge, is there any physical reason why your son/daughter should not participate in this particular sport?
		Yes
		No

Other Medical or Special Needs:

Explain:

Parent's/Guardian's Signature:	*



CONCUSSION HISTORY STATE LAW REGARDING SPORTS-RELATED HEAD INJURY & CONCUSSIONS The Commonwealth of Massachusetts Executive Office of Health and Human Services now require that all schools subject to the Massachusetts Interscholastic Athletic Association (MIAA) rules adhere to the following law. Student-athletes and their parents, coaches, athletic directors, school nurses, and physicians must learn about the consequences of head injuries and concussions through training programs and written materials. The law requires that athletes and their parents inform their coaches about prior head injuries at the beginning of the season. If a student athlete becomes unconscious during a game or practice, the law now mandates taking the student out of play or practice, and requires written certification from a licensed medical professional for “return to play.” Parents and students who plan to participate in any athletic program at Algonquin Regional High School must also take a free on-line course. Two free on-line courses are available and contain all the information required by the law. The first is available through the National Federation of High School Coaches. You will need to click the “order here” button and complete a brief information form to register. At the end of the course, you will receive a completion receipt. The entire course, including registration, can be completed in less than 30 minutes. http://www.nfhslearn.com/electiveDetail.aspx?courseID=15000 The second on-line course is available through the Centers for Disease Control and Prevention at: www.cdc.gov/Concussion By typing your name on this form, you have read the above and completed one of the courses listed as well as referencing the concussion protocol as stated in the Guide to Athletics. This is required in order to participate on any athletic team at Algonquin Regional High School. Thank you very much. Please give us all that you know about the concussion history of the student named in this form.

Most Recent Concussion Date:	*

Parent's/Guardian's Signature:	*



NEW OPIOID LAW On March 14, 2016 Governor Charlie Baker signed landmark legislation into law to address the deadly opioid epidemic plaguing the Commonwealth. The bill is titled An Act relative to substance use, treatment, education and prevention. This new law includes multiple provisions including a 7-day limit on every opiate prescription for minors (with certain exceptions), a mandate for a verbal screen for substance use disorders in students and a requirement that information on opiate-use and misuse be disseminated to all students participating in an extracurricular athletic activity prior to their athletic season. This information can be found at our sports concussion website (www.mass.gov/sportsconcussion) at http://www.mass.gov/eohhs/gov/departments/dph/programs/community-health/dvip/injury-prevention/substance-use-disorder.html. Here you will find information on substance use and misuse, where to get help for your child, resources and a link to the Dept. of Public Health Bureau of Substance Abuse Services. Please make sure prior to every sports season that this educational information is distributed to all student athletes and their parents participating in extracurricular sports. Also, trainings for school health personnel in screening for substance use are currently underway and your school health personnel are encouraged to attend one of these free programs provided by the Department of Public Health. Please visit the following links for more information on preventing the misuse of OPIOIDS: http://masstapp.edc.org/sites/masstapp.edc.org/files/MassTAPP-OpioidAbuse-StudAth-preventing_v2.pdf#overlay-context=preventing-prescription-opioid-misuse-among-student-athletes http://masstapp.edc.org/sites/masstapp.edc.org/files/MassTAPP-OpioidAbuse-StudAth-injurymgt_v2.pdf#overlay-context=injury-management-key-component-prescription-opioid-misuse-prevention http://masstapp.edc.org/sites/masstapp.edc.org/files/MassTAPP-OpioidAbuse-StudAth-PrescOpioids_v3.pdf#overlay-context=what-know-about-prescription-opioids http://masstapp.edc.org/sites/masstapp.edc.org/files/MassTAPP-OpioidAbuse-StudAth-communications_v2.pdf#overlay-context=guidance-communications-after-non-concussion-sports-injury By typing your name on this form you indicate that you have read the New Opioid Law.

Parent's/Guardian's Signature:	*

Student-Athlete Signature:	*



PERMISSION FOR EMERGENCY TREATMENT On rare occasions, a medical emergency arises when we are unable to contact the parents. Most hospitals frown upon administering any medical care without the consent of the parent. In order that no delay occurs that might cause severe discomfort to the student, or endangering the student’s life, we request the following permission slip be signed by the parent. My signature at the end of this form hereby grant permission to the Director of Health Services, to hospitalize, and secure proper treatment for my son/daughter, in the case of medical emergency, provided he is unable to contact me, and according to his best professional judgment, further delay would cause severe discomfort or jeopardize the life of my son/daughter.



SIGNATURE AND AUTHORIZATION I/We - student, parent, legal guardian or parent having legal custody of the student certify that we have read the Guide to Athletics at Algonquin Regional High School, and understand the rules and guidelines stated, and agree to abide by the same. The guide may be found on the Algonquin website at http://algonquin.nsboro.k12.ma.us/pages/ARHS. I/We consent to said student participating in the sport selected above and we understand the term “participation” means all travel and practice sessions connected with the sport in addition to actual games and contests. I/We agree to hold the Northborough/Southborough Regional School District, its staff and the Towns of Northborough and Southborough free and harmless from any injury, loss or damage to us or the student arising out of participating in said sport. By clicking SEND on this form, you authorize that you are the legal parent of the student named in this form and that you recognize that this is your legal and binding electronic signature and that any fraud or inaccuracy will void this student's eligibility. My signature below indicates that I/we have read this entire document and understood it completely.

Type Name here to Signify You Agree:	*

NOTE: If you choose to receive a copy of the completed form, you will NOT be able to see it in the email as this will be transmitted securely AND email is not secure. Please double check on the fields before submitting.

Send a copy of the completed form to this email address :

* Indicates Required fields.