Jefferson Academy
Athlete Emergency Information Form

Athlete Name: ________________________________________ Grade: _________

Mother/Father Names: ___________________________________________________

Address: ____________________________________________

             _____________________________________________

Mother Phone #’s: Home-__________________ Work-__________________ Cell-__________________

Father Phone #’s: Home- __________________ Work-__________________ Cell-__________________

Emergency Contact #1 – MOTHER or FATHER @ above phone numbers (circle one)

Emergency Contact #2 – MOTHER or FATHER @ above phone numbers (circle one)

Emergency Contact #3 - Name:________________________________________

Phone #’s: Home-__________________ Work-__________________ Cell-__________________

Emergency Contact #4 - Name:________________________________________

Phone #’s: Home-__________________ Work-__________________ Cell-__________________

Athletic Participation Checklist

The following criteria must be turned in to the Athletic Office ON OR BEFORE the first day of practice for all Junior/Senior High athletes. Failure to follow these guidelines will result in athlete’s inability to begin practice with their team. If you have any questions/concerns, please call Ken Kain, Linda Balogh or Cindi Dixon at the secondary office.

____ 1. Signed Code of Conduct

____ 2. Medical Release Form with all sections completed and signed

____ 3. Athletic Fee Form completed with payment attached (HS Golf $200, Cheer $50, JH/HS all other sports $100)

____ 4. Athlete Emergency Information Form

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