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Derby Fall Athletic Registration
Derby Fall Athletic Registration

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Price: $135.00

Product Code: 2018-19_DER_ATH_F

General Student Information

Student First Name*:

Student Last Name*:


Date of Birth*:


Does The Student Have an Epi-Pen?*:

Does The Student Have an Inhaler?*:

Sports Information

Fall Sport*:

Details regarding fees.


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*:

Derby Fall Athletic Registration

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