Athlete’s Information
*required field

*Athlete’s first name

*Athlete’s last name

*Athlete’s email address

*Athlete’s address

*Athlete’s city

*Athlete’s state

*Athlete’s zip

*Athlete’s home phone

Athlete’s cell phone

*Year at SICP (Check one)

Frosh

Soph

Junior

Senior

*Athlete birthdate (00-00-00)

Varsity Team or
Novice Team

 Men’s Team or
 Women’s Team

Mother’s information

*Mother’s name

Mother’s address (if different from above)

Mother’s city (if different from above)

Mother’s state (if different from above)

Mother’s zip (if different from above)

Mother’s home phone (if different from above)

Mother’s work phone

Mother’s cell phone

Mother’s email address (one parent mandatory)

Father’s information

*Father’s name

Father’s address (if different from above)

Father’s city (if different from above)

Father’s state (if different from above)

Father’s zip (if different from above)

Father’s home phone (if different from above)

Father’s work phone

Father’s cell phone

Father’s email address (one parent mandatory)

Medical Information

*EMERGENCY ROOM STAFF:
I hereby give my permanent consent to the Hospital Emergency Room staff to treat my child in an emergency type situation in the event it is impossible to reach me personally.  

 Yes

No

The emergency room treatment will be covered by: 

Name of health insurance company

Health insurance policy number

*Emergency contact person  #1 (other than parent)

*Emergency contact person #1 phone

Emergency contact person  #2 (other than parent)

Emergency contact person
#2 phone

*Athlete’s doctor

*Athlete’s doctor’s phone number

*Hospital of choice

Known allergies

List any medications and dosage (1)

List any medications and dosage (2)

*Does your child have asthma?

Yes

No

Club Dues
(Details found in downloaded documents.  Please select one option)

I will send a check for $875 (or $895 if you are new rower) made payable to “Ignatius Chicago Crew”

I have contacted Treasurer Jim Petersen regarding a scholarship request or payment arrangements

I will return the required forms, but payment will be made according to the invoice deadlines stated in the Fall packet

IHSA Pre-Participation Examination
(Please select one option)

 I have downloaded the attached form and will return the document with my packet. 
(A new form is due each year.)  I understand I will not be allowed to practice until this document is submitted to ICC.

I am a freshman and have previously tendered the physical to SICP.

I have a physical examination scheduled on the following date:

I have turned in a physical examination to SICP this school year.  Please contact the school to confirm this.