SMWS Sport Registration + Athletics FormsFor more information, contact: Mike Hawkes | Phone: 303-951-8572 | mikeh@smwaldorf.org Student Athlete InformationFirst Name * Last Name * Email * Grade *6th7th8th9th10th11th12th Which Sport(s) are you registering for? Check all that apply. *MS VolleyballMS Cross CountryHS VolleyballHS Cross CountryMS Girls BasketballMS Boys BasketballHS GIrls BasketballHS Boys BasketballMS Track & FieldHS Track & Field Student Health HistoryHave you ever been hospitalized or had surgery? *YesNo Are you presently taking any medications or pills? *YesNo Do you have any allergies (food, medicine, bees, or other stinging insects)? *YesNo Have you ever experienced any of the following during or after exercise: been dizzy, passed out, had chest pain, had coughing or trouble breathing? *YesNo Do you tire more quickly than your friends during exercise? *YesNo Have you ever had any of the following: high blood pressure, racing of the heart, skipped heartbeats, or diagnosis of a heart murmur? *YesNo Has anyone in your family died of heart problems or a sudden death before age 50? *YesNo Have you ever had a head injury, a seizure or been knocked out or knocked unconscious? *YesNo Have you ever been dizzy in the heat or passed out in the heat? *YesNo Do you have any skin problems (itching, rashes, acne)? *YesNo Have you ever had any of the following: pinched nerve, stinger, burner, heat cramps, or muscle cramps? *YesNo Do you use any special equipment (pads, braces, neck rolls, mouth guard, eye guards, etc.)? *YesNo Have you had any problems with eyes or vision, or wear glasses, contact lenses or protective eyewear? *YesNo Have you ever had an injury or injuries to the back, ribs, chest or neck? *YesNo Have you ever sprained/strained, dislocated, fractured, broken or had repeated injuries of any bones or joints in the shoulder, arm, forearm, elbow, wrist or hand? *YesNo Have you ever sprained/strained, dislocated, fractured, broken or had repeated injuries of any bones or joints in the hip, pelvis, thigh, knee, shin/calf or foot? *YesNo Have you had any other medical problem (including infectious mononucleosis, diabetes, etc.) not yet mentioned? *YesNo Have you had a medical problem or injury since your last evaluation by a doctor? *YesNo When was your last tetanus shot? * When was your last measles immunization? * If you answered "yes" to any of the above questions, please provide more information. What is the name of your sports physician? * What is the phone number of your sports physician? * Athletic Forms AcknowledgementsPlease read the Athletic Intentions, Behavioral and Academic Eligibility Requirements and the Warning to Students and Parents. Click for Athletics Forms. I acknowledge that I have read the information about Athletic Intentions, Behavioral and Academic Eligibility Requirements and the Warning to Students and Parents. I will abide by the guidelines and requirements. *YesNo I acknowledge that my answers on the Student Health History questionnaire are true and correct, to the best of my knowledge. *YesNo VerificationPlease enter any two digits with no spaces (Example: 12) *This box is for spam protection - please leave it blank
