SUSPENDED FORM

Date of Birth

Address

Participant Grade Level in the 2015-2016 School Year

Name of School

Parent/Guardian Name 1

Parent/Guardian Email 1

Parent/Guardian Cell Phone 1

Parent/Guardian Name 2

Parent/Guardian Email 2

Parent/Guardian Cell Phone 2

Are you registering for football, cheer or track?

Physician Name:

Physician Phone:

Name of Health Insurance Provider:

Policy #

Insurance Phone:

List medications being taken by the participant.
Type "none" or "n/a" if none

Medical History: Please list any medical conditions (allergies, asthma, etc.) and medications being taken by the participant named above. List any other information you may deem relevant, and helpful to emergency medical personnel.

Emergency Contact Name:

Emergency Contact Phone:

Additional Comments or questions?

Parent/Guardian Digital Signature
WAIVER OF CLAIMS: "I hereby release any claim I might have against Unity Select Sports, or any of its agents, from any injury or other damage my child might incur while participating in the activity I am registering for. By completing this registration, I acknowledge that my child is physically able to participate in contact sports and this has been verified by a physician within the past 12-months. Upon signing I further acknowledge I have completed this form with all truth and I have revealed all pre-existing medical conditions (if any)." (TIP: PLACE CURSOR IN THE BOX & SIGN YOUR NAME USING YOUR COMPUTER MOUSE.)

Clear

Terms of Service

I understand my online registration is not complete until full payment or a deposit has been processed. By clicking "Register", you will be redirected to a secure payment portal. Please type participants name and grade level in the description box of the payment site.