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Athletics Registration Form

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  Pay to Play Fee - $50
  
  A fee reduction or full fee waiver
  may be available on an as needed basis.
  
  Please contact the Athletic Director to discuss.
  
  Sport REQUIRED Please fill out this field.
  
  Student Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field.
  
  Team REQUIRED Girls' Team Boys' Team Please fill out this field.
  
  Parent/Guardian Name REQUIRED Please fill out this field. Please enter valid data.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Home Phone Number REQUIRED Please fill out this field. Please enter a phone number.
  
  Mobile Phone Number Please enter a phone number.
  
  Insurance Provider REQUIRED Please fill out this field. Please enter valid data.
  
  Primary Doctor's Name REQUIRED Please fill out this field. Please enter valid data.
  
  Hospital Preference REQUIRED Please fill out this field. Please enter valid data.
  
  Allergies/Medication REQUIRED Please fill out this field. Please enter valid data.
  
  Emergency Contact Name REQUIRED Please fill out this field. Please enter valid data.
  
  Emergency Contact Relationship REQUIRED Please fill out this field. Please enter valid data.
  
  Emergency Contact Phone Number REQUIRED Please fill out this field. Please enter valid data.
  
  I give my child permission to participate in SMC/St. Brigid for the 2019-2020 season.
  
  I Agree Please select this field.
  
  Any questions? Contact the Athletic Director
  
  Submit
  
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- Contact Us
  
  William Burke
  
  Principal
  
  william.burkeportlanddiocese.org