SOVA Athlete Registration
This form is to be completed by the Athlete, parent/ guardian or other representative with accurate
knowledge of the Athlete’s medical history. Please fill out as much information as completely as possible.
Are you an Athlete completing this form for yourself:
Yes
No - I am completing this form on behalf of an Athlete
Are you able to consent to medical treatment on your own behalf?
Yes
No
Are you able to sign legal documents for yourself?
Yes
No
Name of Person Completing this Form:
Your Relationship to Athlete
Parent/ Guardian
Caregiver
Family Member
Healthcare Provider
Coach
Other
What is your relationship to the Athlete?
Does the Athlete have the capacity to consent to medical treatment on their own behalf?
Yes
No
Does the Athlete have the capacity to sign legal documents
on their own behalf?
Yes
No
Athlete Information
Full First Name
Middle Name
Last Name
Preferred First Name / Nickname
Date of Birth (MM/DD/YYY)
Gender
Please select...
Male
Female
Non-Binary
Prefer Not To Say
Language(s)
English
French
Spanish
American Sign Language (ASL)
Other
Please List:
Race/ Ethnicity
American Indian / Alaskan Native
Asian American
Black / African American
Hispanic / Latino
Middle Eastern / North African
Native Hawaiian / Other Pacific Islander
White / Caucasian
Unknown
Prefer not to answer
Other
Please List:
Athlete Contact Information
Email
Phone Number
Area (if known)
Please select...
Area 02
Area 03
Area 04
Area 05
Area 06
Area 07
Area 08
Area 09
Area 10
Area 11
Area 12
Area 13
Area 14
Area 15
Area 16
Area 17
Area 18
Area 19
Area 20
Area 21
Area 22
Area 23
Area 24
Area 25
Area 26
Area 27
Area 28
Area 29
Area 30
Area 31
Area 33
Phone Type
Mobile
Landline
Home Address
City
State
Zip Code
Parent/ Guardian Information
Athlete is over 18 and can sign for self
Same contact info as Athlete
First Name
Last Name
Relationship to Athlete?
Email
Phone Number
Phone Type
Mobile
Landline
Home Address
City
State
Zip Code
Emergency Contact
First Name
Last Name
Phone Number
Phone Type
Mobile
Landline
Relationship to the Athlete
Parent/ Guardian
Caregiver
Family Member
Healthcare Provider
Coach
Other
Relationship to the Athlete?
Associated Conditions
Check all that Apply:
Autism
Cerebral Palsy
Down Syndrome
Fetal Alcohol Syndrome
Marfan Syndrome
Spina Bifida
Epilepsy
Fragile X Syndrome
Unknown
Other
Please specify other known intellectual disability diagnoses:
Please specify any behavioral, mental health, and/or sensory conditions:
Assistive Devices and Accomodations
Do you use any of the following? Check all that apply:
Mobility:
Walker
Braces or crutches
Wheelchair
Removable orthotics
Prosthetics
Lifestyle Aids:
CPAP
Glasses, contact lenses, or protective eyewear
Dentures
Communications:
Hearing Aid
Communication devices
Sign Language
Medical Devices:
Implantable cardioverter defibrillator (ICD)
VP Shunt
Implantable device for seizure management
Pacemaker
Other Assistive Devices if Used:
General Health Questions
Do you have a heart condition?
Yes
No
Do you have asthma?
Yes
No
Do you have diabetes that requires you to take insulin?
Yes
No
Do you have a vision impairment?
Yes
No
Do you have a hearing impairment?
Yes
No
Do you have a bleeding disorder?
Yes
No
Has a doctor ever limited your participation in sports?
Yes
No
Do you have epilepsy or any type of seizure disorder?
Yes
No
Do you have sickle cell disease?
Yes
No
Have you ever had a concussion?
Yes
No
Please specify how many in your lifetime:
Date of last one (mm/yyyy)
Do you have severe allergies that requires the use of an EpiPen?
Yes
No
Please specify:
Insect Stings
Medication/drugs
Food
Latex
Other
Please specify:
Do you have a specific dietary requirement
Yes
No
Please specify:
Medication and Treatment
Are you taking any prescription or over-the-counter medications or treatments? (Including birth control pills, insulin, multivitamins,
allergy shots or pills, EpiPen, asthma inhalers, epilepsy medication, anti-inflammatory medication, supplements of any kind. etc.)
Yes
No
Medication, Vitamin, or Supplement Name
Dosage
Times per day
Contact Information