FALL 2015 NHS ATHLETICS SEASONAL REGISTRATION FORM
FALL 15 GOLD
**CURRENT DOCTOR'S PHYSICAL MUST BE SUMBITTED WITH REGISTRATION FORM**
Pre-Registration: June 1-24, 2015 (Submission Deadline August 17, 2015)
User Fee = $285.00 (Club $225.00)
CHECKS DUE BY 9/8/15
Plus Surcharges RATES LISTED Below
Please drop off or mail REGISTRATION FORMS & DOCTOR'S PHYSICAL FORMS to: NHS Athletic Department or Fax to: 781-455-0818
USER FEE PAYMENTS can be dropped off starting 8/17/15, mailed or paid online at https://www1.mcc.net/OneSource/OSPayer/
STUDENT ATHLETE & PARENT/GUARDIAN INFORMATION (please print)
Student Name:
Gender:
Year of Graduation:
Email Address:
Cell #:
Date of Birth:
Parent/Guardian 1:
Parent/Guardian 2:
Email Address:
Email Address:
Home Phone #:
Cell #
Home Phone #:
Cell #
MEDICAL INFORMATION
PLEASE CIRCLE ALL THAT APPLY TO YOUR CHILD OR NONE
Life Threatening Allergies
Cardiac Conditions
Missing Paired Organ (i.e. Kidney, Lung)
Diabetes
Carries EpiPen
Carries Inhaler
Recent Surgery
Seizures or Convulsions
NONE
PLEASE EXPLAIN CIRCLED CONDITIONS:
List all Current Medications:
List Other Medical Conditions:
HEAD INJURY / CONCUSSION REPORTING (State-Mandated)
YES
Has Student ever experienced any traumatic head Injury?
/
NO
If 'Yes' - Please provide the following information for each head injury experienced:
Date of Injury:
Medical Attention Received: Yes / No
Concussion Diagnosed: Yes / No
Date of Injury:
Medical Attention Received: Yes / No
Concussion Diagnosed: Yes / No
Please provide information about the duration of symptoms for most recent concussion (such as headache, fatigue, difficulty concentrating):
Has Student been cleared to return to full academics? Yes / No
Date:
Has Student been cleared to return to full Athletics? Yes / No
Athletic Office Use Only:
Physical Date:
Nurse Signature:
Date:
(If 'Yes' - Please attach copy of Doctor's clearance note)
Updated Physical:
NOT MEDICALLY CLEARED
Date:
PLEASE CHECK THE SPORT YOUR CHILD WILL PARTICIPATE IN FOR THE FALL 2015 SEASON
FALL 2015
V/JV Football, Var Dance & Cheer Start Monday 8/24/15; All Other Sports Start Thursday 8/27/15
( ) Cheerleading - Var (cuts) Tryouts held Spring '15
( ) Boys & Girl's Cross Country - V/JV (no cuts)
( ) Golf - Var (cuts)
( ) Field Hockey - V/JV/9th (cuts may be needed)
( ) Girls Soccer - V/JV/9th (cuts may be needed)
( ) Football - V/JV/9th (no cuts) ( ) Club Cheerleading (possible cuts)
( ) Boys Soccer - V/JV/9th (cuts)
( ) Girls Volleyball - V/JV/9th (cuts)
( ) Club Dance (cuts possible)
( ) Dance - Var (cuts) Tryouts held Spring '15
( ) Girls Swiming & Diving - V/JV (cuts may be needed) - plus Surcharge $50
( ) Sailing (no cuts) Plus Surcharge of $175
FALL CLUB SPORTS (Fee $225)
Visit http://nhs.needham.k12.ma.us/athletics for links to all forms, program information and team schedules.
PERMISSION & RELEASE
I give permission for my son / daughter ________________________to participate in any of the 2015-16 interscholastic sports listed above at:
Needham High School. My son / daughter and I have read and understand the school, district and state athletic regulations, including Academic
Eligibility, MIAA Chemical Health (drugs & alcohol), Bullying/Hazing and Bona Fide Team Member policies, as outlined in the NHS Student-Athlete
Handbook, and understand rules will be enforced.
I/We further agree not to hold the Town of Needham, the Needham Public Schools and/or their employees, agents and assigns, responsible for
any injury occurring to my son / daughter in the proper course of such interscholastic sport(s) or related travel. In case of accident, I give
permission to have my son / daughter treated for any medical emergency that might arise in the event I cannot be contacted, or in extreme
emergency, where immediate treatment is necessary. I/We accept full responsibility for costs of any such emergency treatment.
Parent/Guardian Signature (required):
Date:
Student Signature (required):
Date:
*We have also reviewed and understand
the concussion treatment/recovery
policies and procedures as documented in
the NHS Student-Athlete Handbook and
have fulfilled the State-Mandated
concussion education component (required
once each school-year prior to first athletic
season of participaton) by completing the
free online course at:
www.cdc.gov/concussion.
(Mass General Law Chapter 166)
PLEASE CHECK THE SPORT(S) YOUR CHILD INTENDS TO PARTICIPATE IN FOR THE 2015-16 SEASONS
WINTER 2015-2016
Practices/Tryouts for all winter sports start on November 30, 2015
( ) Boys Basketball - V/JV/9th (cuts)
( ) Dance - Var (cuts)
( ) Girls Basketball - V/JV/9th) (possible cuts) ( ) Boys Ice Hockey -V/JV (cuts) Surcharge $250
( ) Cheerleading
( ) Squash Plus Surcharge $175
( ) Cheerleading - Var (cuts)
( ) Wrestling - V/JV (no cuts)
( ) Gymnastics V/JV (cuts may be needed)
( ) Dance
( ) Bowling Plus Surchage $75
( ) Boys / Girls Alpine Skiing - V/JV (cuts possible) Surcharge $250
SPRING 2016
WINTER CLUB SPORTS (Fee $225)
( ) Girls Ice Hockey - V/JV (cuts) Surcharge $250
( ) Fencing
( ) Boys / Girls Indoor Track - V/JV (no cuts) ( ) Boys Swim & Dive - V/JV (no cuts) Surcharge $50
Plus Surcharge $125
Practices/Tryouts for all spring sports start on March 21, 2016
( ) Snowboarding
Plus Surchage $75
SPRING CLUB SPORTS (Fee $225)
( ) Baseball - V/JV/9th (cuts)
( ) Boys Lacrosse - V/JV/9th (cuts may be needed)
( ) Boys Tennis - V/JV (cuts)
( ) Sailing (possible cuts) Plus Surcharge $175
( ) Girls Lacrosse - V/JV/9th (cuts may be needed)
( ) Softball - V/JV/9th (cuts may be needed)
( ) Girls Tennis - V/JV (cuts possible)
( ) Boys / ( ) Girls Ultimate Frisbree (no cuts)
( ) Boys Volleyball - V/JV (cuts may be needed)
( ) Boys / Girl's Track & Field- V/JV (no cuts)
( ) Rugby (no cuts)
( ) Water Polo (no cuts) Plus Surcharge of
$75
REGISTRATION FORMS ARE DUE FOR EACH NEW SEASON: ***WINTER DUE DATE 11/17/15*** ***SPRING DUE DATE 3/11/16*** (
) Check if submitting updated form
* * * FALL ATHLETE MEDICAL STATUS UPDATE REQUIREMENT * * *
Any student suffering an injury (head trauma or other) after handing form in, but before start of the Fall Season, is required to
report the injury through the submission of a new Registration From along with a Physician's note.