Athletic Registration Form
Athletics Registration Form

Please fill this out and then pay your fees to register for activities.
 
STUDENT INFORMATION:
 
  *
 
  *
 
  *
 
  *
 
  *
 
  *
 
  *
 
  *
 
  *
 
  *
 
* Winter Sport
     
     
     
     
     
     
     
     
     
 

 

PARENT/GUARDIAN INFORMATION

 
  *
 
  *
 
  *
 
  *
 
  *
 
  *
 
  *
 
  *
 
  *
 

 
 
AUTHORIZED PERSON TO CONTACT IN CASE OF AN EMERGENCY
I.E.- Grandfather, Grandmother, family friend

 
 
  *
 
  *
 
  *
 
  *
 
  *
 
  *
 

 
 
PRIMARY CARE DOCTOR INFORMATION
 
  *
 
  *
 
  *
 
  *
 
  *
 

 

STUDENT/ATHLETE HEAD INJURY HISTORY

Pursuant to Massachusetts General Law, Chapter 111, Section 222, participants of interscholastic athletic programs and their parents prior to each season must disclose any information relative to any sports head injury history.  this information must be shared with the athlete's coach(s) and a copy will be kept on file in the offices of the Director of Athletics and the School Nurse.
 
 
  Have you every exhibited signs, symptoms or behaviors consistent with a concussion (such as loss of consciousness, headache, dizziness, confusion, or balance problems) during a sporting competition at any level? 
     
     
 
  Have you ever been diagnosed with a concussion? 
     
     
 
 
 
  Do you currently have or have you ever had athletic participation restrictions in relation to being diagnosed with a concussion? 
     
     
 

 
 
STATE LAW REGARDING SPORTS-RELATED INJURY AND CONCUSSIONS

The commonwealth of Massachusetts Executive Office of Health and Human Services now require that all schools subject to the Massachusetts Interscholastic Athletic Association (MIAA) rules adhere to the following law.  (These rules, specific to head injury, will govern all schools in the Ashburnham-Westminster Regional School District.) Student-athletes and their parents, coaches, athletic directors, school nurses, and physicians must learn about the consequences of head injuries and concussions through training programs and written materials.  The law requires that athletes and their parents inform their coaches about prior head injuries at the beginning of the season.  If a student athlete becomes unconscious during a game or practice, the law now mandates taking the student out of play or practice, and requires written certification from a licensed medical professional for “return to play”.

 Parents and students who plan to participate in any athletic program representing the Ashburnham/Westminster Regional School District must also take a free on-line course.  Two free on-line courses are available and contain all the information required by law.  The first is available through the National Federation of High School Coaches.  You will need to click the “order here” button and complete a brief information form to register.  At the end of the course, you will receive a completion certificate.  The entire course, including registration, can be completed in less than 30 minutes.

PLEASE SUBMIT REGISTRATION FORM BY CLICKING "SEND" AT THE BOTTOM OF PAGE BEFORE TAKING CONCUSSION CLASS

www.nfhslearn.com

 The second on-line course is available through the Centers for Disease Control and Prevention at:

 www.cdc.gov

 The Oakmont/Overlook Athletic Department will also provide student-athletes and their parents, a concussion education presentation.  This presentation will take place as part of our “Parent Night” held before each of our three sports seasons; and conducted by one of our local medical professionals.

 

 

 
COMMONWEALTH OF MASSACHUSETTS OPIOID LAW- AN ACT RELATIVE TO SUBSTANCE USE, TREATMENT, EDUCATION AND PREVENTION
 
On March 14, 2016, Governor Charlie Baker signed landmark legislation into law to address the deadly opioid epidemic plaguing the Commonwealth.  The bill is titled 'An Act relative to substance use, treatment, education, and prevention'.  The new law includes multiple provisions including a 7-day limit on every opiate prescription for minors, a mandate for a verbal screen for substance use disorders in students and a requirement, that information on opiate-use and misuse be disseminated to all students participating in extracurricular athletic activity prior to their athletic season.  This information can be found at :  http://masstapp.edc.org/rx-student-athlete
 

 
 
OAKMONT/OVERLOOK ATHLETE PARTICIPATION 

"CHEMICAL HEALTH POLICY REFERENCE"

 

Any athlete or co-curricular activity participant at Oakmont Regional High School is a highly visible representative of the Ashburnham Westminster Regional School District.  Since Oakmont has a 100% zero tolerance policy for alcohol, drug, and tobacco use, we expect that our athletes and activity participants will model their behavior in a manner that supports this policy at all times. Remember, you made a choice to become a student athlete and/or activity participant.  With that choice come certain responsibilities.

 The following Massachusetts Interscholastic Athletic Association (MIAA) Provision

(Rule 62.1, page 55, MIAA Handbook) that is mandatory for all Oakmont athletes will also be binding to all co-curricular activity participants:

 “From the first allowable day of fall practice through the end of the academic year or final competition of the year, whichever is later, a student shall not, regardless of the quantity, use, consume, possess, buy/sell, or give away any beverage containing alcohol; any tobacco product (including e-cigarettes); marijuana; steroids; or any controlled substance.  This policy includes products such as NA or near beer. It is not a violation for a student to be in possession of a legally defined drug specifically prescribed for a student’s own use by his/her doctor. This rule represents only a minimum standard upon which schools may develop more stringent requirements.”

 The above policy is in effect at all times, whether in school or outside of school!

Student athletes/activity participants that attend unsupervised student gatherings where they find that alcohol is readily available, the illegal use of controlled substances is prevalent, and/or tobacco products are in use, are expected to exercise their better judgment and remove themselves from this situation as soon as they become aware that these actions are taking place within their immediate environment.

The athlete/activity participant and parent signatures below signify acceptance of the above policy. Penalties for violation of the above policy will result in suspension from athletics, or activity, as required by the MIAA (please see other side). It can also result in disciplinary action as warranted by the Oakmont Student Handbook, team or activity penalties imposed by the coach or advisor, and possible dismissal from the sport or activity.

Our signature below indicate that we have read this entire document and understand it completely.

 
  *
 

 
 ASHBURNHAM-WESTMINSTER REGIONAL SCHOOLS

Athletics Parental Consent Form

Release from Liability and Indemnity Agreement

Medical Emergency Treatment Authorization

I/We do hereby CONSENT to my son/daughter's voluntary participation in athletic programs sponsored by the Ashburnham-Westminster Regional Public Schools (hereinafter referred to as the “voluntary sports programs”). I/We RELEASE and discharge The Ashburnham Westminster Regional School District, the Towns of Ashburnham and/or Westminster and its departments, officers, employees, administration, school committee and agents (hereinafter collectively referred to as “Ashburnham-Westminster”) from any and all claims, damages, losses, or expenses of whatever kind or nature which said minor may have or acquire arising out of or resulting from, directly or indirectly, his/her participation in the voluntary sports program. I/We furthermore agree to defend and IDEMNIFY Ashburnham-Westminster against any claim, damage, loss or expense of whatever kind or nature that Ashburnham-Westminster may have to pay that arises from said minor’s intentional, grossly negligent, or reckless acts or omissions while participating in the voluntary sports programs.

 I/We understand that sports in the voluntary sports programs are inherently dangerous activity and that there are genuine and serious risks to anyone who engages in this activity. Due to the nature of sport and physical activity, I/we understand that the risks involved include, without limitation, a full range of injuries, including potential catastrophic injury resulting in permanent paralysis, brain injury, or death.

 I/We hereby authorize Ashburnham-Westminster’s employee(s) or agent(s) who is supervising said minor to act on our behalf in authorizing and consenting to emergency medical care for said minor if he/she becomes ill or is injured while participating in the voluntary sports programs. This Authorization and Consent may be presented to the appropriate emergency medical staff at such time as emergency medical care is required. I/We hereby RELEASE and discharge Ashburnham-Westminster from any and all claims of any nature whatsoever, which may arise out of the decision to provide emergency medical care.

 My signature below indicates that I/we have read this entire document and understood it completely.

 
  *
 
SIGNATURE AND AUTHORIZATION

By clicking SEND on this form, you authorize that you are the legal parent of the student named in this form and that you recognize that this is your legal and binding electronic signature and that any fraud or inaccuracy will void this student's eligibility.
 




  Send a copy of the completed form to this email address : 


* Indicates Required fields.