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This form must be completed for all participants who are under 18 years of age.

Name: *
  
Date of Birth: *
  
Age: *
  
Sex: *
  
Name of Parent or Guardian: *
  
Home Address: *
  
City: *
  
State: *
  
Zip: *
  
Home Phone: *
  
Cell Phone: *
  
If the person above is not available in the event of an emergency, notify:
Emergency Contact Name #1: *
  
Relationship: *
  
Phone: *
  
Emergency Contact Name #2: *
  
Relationship: *
  
Phone: *
  
Name of Personal Physician: *
  
Phone: *
  
Health/Accident Insurance Carrier: *
  
Policy Number: *
  
Initials of Acceptance (Parent or Guardian): *
  
In the case of emergency, I understand every effort
will be made to contact me. In the event I cannot be
reached, I hereby give my permission to the physician
selected to secure the proper medical treatment, which
may include hospitalization, anesthesia, surgery or
injection of medication for my son/daughter. By placing
my initials in this box I agree to the statements.
Medical Information:  
Asthma
Cancer
Convulsions
Diabetes
Heart Disease
Hemophilia
High Blood Pressure
Leukemia
Other (Describe Below)
  
past or present information / check all that
apply and provide necessary details
Medical Explanations:  
  
Allergies:  
Food
Plants
Medicines
Insect Bites
Other
  
please check all that apply and provide necessary details
Allergy Explanations:  
  
Special Equipment?:  
  
such as orthopedic or handicap devices,
glasses or contacts, dentures
Special Equipment Explanation:  
  
Date of Last Tetanus Shot:  
  
 
  * indicates required information