Step 1 of 3 33% Athlete Name* First Last Gender*MaleFemaleBirthdate* Current Grade Level of Athlete*6th Grade7th Grade8th GradeFreshmanSophomoreJuniorSeniorFall Sports/Sport Activities Cross Country Golf Cheerleading Soccer Volleyball Middle School Cross Country Winter Sports/Sport Activities Basketball Bowling Dance Swimming & Diving Archery Spring Sports/Sport Activities Baseball Softball Track and Field Tennis Middle School Track and Field Parent/Guardian Name* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent Phone (#1)*Parent Phone (#2)Parent Email (#1)* Parent Email (#2) SHDHS Athlete-Parent HandbookClick Here to Download the SHDHS Athlete-Parent HandbookSt. Henry District High School Athletic Handbook Agreement*As a students and athlete for St. Henry District High School, I hereby agree that I have received and read the Athletic Handbook for St. Henry District High School. I agree that I will comply with the rules and guidelines outlined in the Athletic Handbook and understand that I must follow these rules at all times. I understand that violations to the specific rules and responsibilities can result in my removal from athletic events and teams in which I participate. This handbook is to be used as a reference tool for general information and I understand that I should seek out either my Head Coach or Athletic Director with questions on specific issues. I understand that failure to sign this form may result in my being declared ineligible for practice or competition. As the parent or legal guardian of the student signing below, I agree that my child will follow the provisions of the St. Henry District High School Athletic Handbook We have read and will abide by the policies and guidelines in the Athletic Handbook Authorization for the Release of Health Information (HIPAA)As parent/guardian of ___________________________ (“the athlete”) a student at SHDHS (the “School”) in Erlanger, Kentucky, who desires to participate in the following extracurricular athletic program/s: ___________________________ (the “SPORT or SPORTS”), I understand that in the course of competing in the Program or Program-sponsored events the Student may require attention or assistance from an Athletic Trainer for illness or injury incurred while participating in such Program-sponsored sporting events. I understand that the School has arranged for St. Elizabeth Healthcare to provide such attention and assistance during certain Program-sponsored events. I, the undersigned, hereby authorize St. Elizabeth Healthcare to release all medical information about the Student obtained in the course of providing athletic training attention or assistance during Program-sponsored events to the School and its representatives including, but not limited to, coaches, for the purpose of making determinations regarding the continued participation of the Student in the Program or Program- sponsored sporting events. I understand that I have the right to revoke this authorization at any time except to the extent St. Elizabeth Healthcare has already acted as a result of this authorization. I further understand that any revocation must be provided in writing to St. Elizabeth Healthcare. I also understand that when information is used or disclosed based on an authorization; the information may be re-disclosed by the recipient and no longer protected by the Standards for the Privacy of Individually Identifiable Health Information. This authorization shall expire one year after date signed. I understand that I have the right to refuse to sign this authorization. I further understand that such refusal may result in the Student’s being ineligible to participate in the School’s sporting activities. Release Information Authorization*I give authorization for the release of Health InformationI decline authorization for the release of Health InformationElectronic Signature - Athlete*Electronic Signature - Parent* This iframe contains the logic required to handle Ajax powered Gravity Forms.