Parent/Guardian Name(s):

First Name

Last Name

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Phone Number (Backup)

Youth Name

First Name

Last Name

Birthdate

Grade

Phone Number

T-Shirt Size

Doctor's Name & Phone Number:

Health Insurance Provider & Policy Number:

Allergies

Does your child have any medical conditions or physical limitations?

Does your child carry an EpiPen or inhaler?

Yes

No

Is your child currently taking any medications? (Please list name, dosage, and schedule)

Do you give permission for your child to receive over-the-counter medication if needed (e.g. Tylenol, Benadryl)?

Yes

No

Contact Me First

Do you give permission for emergency medical treatment if a parent/guardian cannot be reached?

Yes

No

Are there any activities your child should not participate in? (e.g. swimming, hiking)

Is there anything else we should know about your child?

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