Health Form

If you are registering as an individual, please enter your team name as "individual" and skip fields regarding the team captain.

Team Name

    

Participant's Name

         

Participant's Grade

    

Team Captain Name

         

Team Captain Email

    

Participant Email

    

Participant Phone

    

Address (please enter on one line)

    

Birthday

    

Gender




Father's Name

        

Father's Phone

 

Mother's Name

        

Mother's Phone

 

With whom does the child reside?




Please list two other responsible adults that we can call if you are unavailable:


Responsible Adult 1

        

Adult 1 Phone

   

Adult 1 Relationship

 

Responsible Adult 2

        

Adult 2 Phone

   

Adult 2 Relationship

 

Doctor to be notified in case of severe emergency

    

Doctor's phone number

    

Preferred Hospital in case of severe emergency

    

Please check the following if they are true.


    

    

    

    

    

    

    

List Medications if applicable

    

List Conditions if applicable

    

What is child allergic to (if applicable)?

    


Insurance Provider

    

Additional Comments or Concerns?

    


Participant Signature

    

Signature Date

    

Parent or Guardian Signature

    

Signature Date