Home >

Derby Winter 1 Athletic Registration
Derby Winter 1 Athletic Registration


 
If you need help with any question, please click on the next to the item below. Many fields have required responses (indicated by *).
Price: $135.00


Product Code: 2017-18_DER_ATH_W1

General Student Information

Student First Name*:


Student Last Name*:


Gender*:


Date of Birth*:
mm/dd/yyyy

Grade*:


Does The Student Have an Epi-Pen?*:


Does The Student Have an Inhaler?*:

Sports Information

Winter Sport*:

Details regarding fees.
Don't see your Unified team?  Click here.

Seasons*:


Position(s):
Position(s) if known or applicable
Phone Numbers

Home Phone #:


Student Cell #:


Mom/Guardn Cell:


Dad/Guardn Cell:

Email Addresses

Student Email:


Mom Email:


Dad Email:

Pre-Participation Physical Exam

Physical Exam*:

Physical Form (Completed After 4/15/2018)
Concussion Awareness

Parent/Guardian Agreement*:


Student Agreement*:

Athletic Participation Parental Approval Form

I Carry Accident/Health Insurance*:


Insurance Company Name:


Parent/Guardian Agreement*:


Student Agreement*:

Athletic Fee and Agreement

Pay to Participate Fee*:


Parent/Guardian Agreement*:


Student Agreement*:


Description
 
Derby Winter 1 Season (Nov - Jan) Athletic Registration