2024-25 Athletic Physical and Authorization Form

2024-25 Athletic Physical Form (to take to the doctor)

If you have any questions about athletic forms, please contact our Sports Information Coordinator Rebecca Kinsley at rebecca.kinsley@charchrist.com.

Student's First Namerequired

Student's Last Namerequired

Grade for 2024-25required

Parent's Preferred E-mailrequired

T-shirt sizerequired

Please select all the sports your child will be participating in this school year.

Does this student have allergies?*

Yes No

Please list ALL allergies here:required

Mother's First and Last Name:required

Mother's Cellrequired

Father's First and Last Namerequired

Father's Cellrequired

Emergency Contact's First and Last Namerequired

Emergency Contact's Cellrequired

All students participating in athletics at Charlotte Christian School must have active health care coverage. Please provide the policy number and insurance carrier name:

Carrier Name:required

Policy Number:required

Please be sure that ALL 4 PAGES of the athletic physical have been completed and signed. You may upload ALL 4 PAGES as one scanned file or you may take a picture of each page individually and upload 4 separate files.

How many files do you need to uploadrequired

Be sure to upload ALL 4 PAGES.

Upload File #1required

Max file size: 10 MB

Upload File #2required

Max file size: 10 MB

Upload File #3required

Max file size: 10 MB

Upload File #4required

Max file size: 10 MB

Did a physician sign this physical?required

What was the date of this exam?required (mm/dd/yyyy)

Please click on each document below to review the information. Then sign below to consent to the releases and statements.

CCS Athletics Authorization, Concussion Information and Duty to Warn
Atrium Health Medical Releases (please note, you do not need to print and sign these, you will sign digitally below)
NCISAA Student Consent to Participate and Release (please note, you do not need to print and sign these, you will sign digitally below)

I give permission for my child to participate in Charlotte Christian athletic activities.required

We have read and consent to the CCS Athletics Authorization, Concussion Information & Duty to Warn Statementrequired

We have read and consent to the Atrium Health Request for Treatment and Release of Medical Informationrequired

We have read and consent to the Atrium Health Photo/Video Communication Authorizationrequired

This is an optional consent.

We have read and consent to the NCISAA Student Consent to Participate and Releaserequired

Digital Signature Acknowledgement - Type names in the box below.

Electronic Signature (eSignature): You consent and agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action while using any electronic form we offer; or in accessing or making any transactions regarding any document, agreement, acknowledgement, consent, term, disclosure, or condition constitutes your signature, acceptance and agreement as if actually signed by you in writing. Further, you agree that no certification authority or other third party verification is necessary to validate your electronic signature; and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature or resulting contract between you and Charlotte Christian School. You understand and agree that your eSignature executed in conjunction with the electronic submission of your form will be legally binding and such transaction will be considered authorized by you.

Type Student's Full Name Here:required

Today's Daterequired (mm/dd/yyyy)

Type Parent's Full Name Here:required

Today's Daterequired (mm/dd/yyyy)