Sports Sign-up Form - St Mary Basha Catholic School

1. Child's First Name *

2. Child's Last Name *

3. Child's Homeroom *

4. Which sport are you signing your child up for? (Note - Soccer is for Jr. High Students only)

5. Parent email *

6. Second email

DRIVER INFORMATION

7. Driver Name *

8. Date of Birth *

9. Address Label *

Address 1
Address 2

City

State

Zip

10. Phone Number *

11. Drivers License Number *

12. Drivers License Expiration Date *

13. Vehicle Owner's Name (if different from the driver)

14. Vehicle Owner's Address (if different from the driver)

Address 1
Address 2

City

State

Zip

15. Make, Model, and Year of Vehicle *

16. License Plate *

17. Insurance Company *

18. Policy Number *

19. Date of Policy Expiration *

When using a privately-owned vehicle, the insurance coverage is the limit of the insurance policy covering that specific vehicle.

Policy Note: The minimal acceptable liability limit is $100,000/$300,000. If your liability limit is less than the acceptable 100/300 limit, you may not drive student athletes other than your own child listed above.

20. Liability Limits of Policy *

21. I understand I may only drive other student athletes if I have the minimum policy $100,000/$300,000 *

Yes, I understand and I have the minimum policy rate. I plan on driving ONLY my child.

I certify that the information given on this form is true and correct to the best of my knowledge. Transportation to away games is needed in order to get all student athletes to their scheduled game. We appreciate those who are able to drive. I understand that as a volunteer driver, I must be 25 years of age or older, possess a valid driver's license, have the proper and current license and vehicle registration, and have the required insurance coverage in effect on any vehicle used to transport students. Additionally, I understand that I must have a current Safe Environment Training (SET).

(You can check your SET or complete the course here: https://phoenix.cmgconnect.org/)

22. Type your Digital Signature *

EMERGENCY INFORMATION

23. Parent/Guardian *

24. Phone # *

25. Parent/Guardian 2 *

26. Phone # 2 *

Alternate emergency contact (in case parent/guardian cannot be reached):

27. Name *

28. Phone Number *

29. Relationship *

Insurance/Health Information:

30. Medication(s) athlete takes regularly *

31. Family Physician *

32. Insurance Carrier *

33. Policy # *

I, the parent/guardian of the student(s) named above, request that the school allow my child(ren) to participate in the C.Y.A.A. after school sports program at St. Mary-Basha Catholic School. I understand that this will include travel to other schools in private vehicles.

Also due to costs, there is a $120.00 fee per child paid through this form via my FACTS account. This is non-refundable to those who drop out of the program, those who are suspended, and those who are academically ineligible due to grades or conduct.

Each child will be issued a uniform and sport specific spirit wear t-shirt. The uniform will be returned at the end of the season, but your child may keep the shirt.

I have read and understand the uniform policies as noted in the SMB Sports Registration Packet and recognize that any failure to return the uniform at the end of the season will result in my being charged a $60 replacement or a $30 cleaning fee if not returned clean.

I understand that my son/daughter is ineligible to participate in another sport until all uniforms are turned in or paid for.

We hereby release St. Mary-Basha Catholic School or any and all of its employees from any and all liability for any harm arising to my/our son(s)/daughter(s) as a result of participating in the C.Y.A.A. after school sports.

34. Child's T-shirt Size (Please specify Child or Adult and size)

35. Digital Signature *