Team Captain Name
Team Captain Email
Address (please enter on one line)
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)?
Additional Comments or Concerns?
Parent or Guardian Signature