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)





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