participationform

Last Name:__________________________________

First Name:__________________________________

_____ M ____ F

CHAMPAIGN CENTENNIAL HIGH SCHOOL
ATHLETIC PARTICIPATION CARD

Please Print the Following Information:
Student Address:______________________________________________Class:    9    10    11    12
City:__________________________ Zip Code:____________________ Phone:___________________ 
Birth Date:______________________Birth Place:___________________________________________
                Month     Day       Year                                      City                     County                         State 
Foreign Exchange Student: YES:________ NO:___________

Mother's Name:__________________________ Address:_____________________________________ 
City:_____________________ Zip Code:____________________ Phone:______________________ 

Father's Name:__________________________ Address:______________________________________ 
City:______________________ Zip Code:____________________ Phone:______________________ 

(If other than a Parent)
Legal Guardian:________________________ Address:________________________________________ 
City:_______________________Zip Code:___________________ Phone:______________________ 

Date of Most Recent Physical Exam:_________________________
School attended last year:____________________________________

In case of emergency, please contact:_______________________________Phone Number:____________
In case of emergency, I would like the above named student to be transported to (circle one): Carle Hospital  or Provena

Fall Sports	Winter Sports	Spring Sports
Football	Boys Basketball	Baseball
Boys Cross Country	Boys Swim	Boys Tennis
Boys Golf	Wrestling	Boys Track
Boys Soccer
Girls Cross Country	Girls Basketball	Softball
Girls Golf		Girls Soccer
Girls Swimming		Girls Track
Girls Tennis
Girls Volleyball
Cheerleaders/ Lancers	Cheerleaders/ Lancers

 I would like to participate in or try-out for the following sports:

Fall Sport: ________________________ (please list sport)
 
Winter Sport: ________________________ (please list sport)
 
Spring Sport: ________________________ (please list sport)

INSURANCE WAIVER AND STATEMENT OF COVERAGE FOR STUDENT ATHLETE

We must ask the parent or guardian to sign the statement below and return it to the athletic department before the individual will be permitted to participate. All injuries must be reported to the coach immediately. If a physician is required, the student shall pick up a claim form in the main office at the school and have the physician complete it. All claims must be filed by the parent when there is payment due for an injury. Information will be given the athlete regarding the exact procedure for filing claims.

I/We understand that the Champaign Community Unit School District #4 does NOT provide accident insurance for participants in interscholastic/intramural athletics. I/We assume full legal responsibility for any damages or injuries sustained by the undersigned student, not covered by insurance purchased by us, and agree to indemnify and hold harmless the above named School District against claims arising therefore.

Please check one: ___ I/We mailed to the student insurance carrier the premium for the optional insurance offered.

   ____ I/We have our own family accident insurance policy.

PARENT PERMIT AND SUBSTANCE ABUSE POLICY

I give permission for my son/daughter to participate in all sports except: (Please list any sport for which you DO NOT give permission.)

__________________________________________________________________

We also affirm that all information stated herein is correct and acknowledge that we have read and fully understand the Unit 4 Substance Abuse Policy and support any penalties which may be enacted.

Parent Signature:___________________________________________________ Date:___________________

Student-Athlete Signature:____________________________________________ Date:___________________

Please attach a copy of the student-athlete's current physical to this form. The Illinois High School Association requires that each student will have on file at their high school a certificate of physical fitness issued by a licensed physician not more than one year preceding practice or participation in any interscholastic athletic contest or activity.