| *Participant's First Name: |
__________________________________ |
| *Participant's Last Name: |
__________________________________ |
| *Address: |
__________________________________ |
| *City: |
__________________________________ |
| *State: |
__________________________________ |
| *Zip: |
__________________________________ |
| *Gender: |
Male Female (circle one) |
| *Birthday: |
__________________________________ |
| *Last Grade Completed: |
__________________________________ |
| *T-Shirt Size: |
__________________________________ |
| *Sponsor Church: |
|
| *Insurance Carrier: |
|
| *Insurance Policy Number: |
|
| *Allergies,Medical,&Special Needs: |
|
| *Date of Last Tetanus Shot: |
__________________________________ |
| *List Medications,Dosages,& times: |
|
| *Can Your Student take Acetaminophen: |
Y N (circle one) |
| *Can Your Student take Ibuprofen: |
Y N (circle one) |
| *Can Your Student take Stomach Ache Remedy: |
Y N (circle one) |
| *Parent/Guardian Name: |
__________________________________ |
| *Home Phone: |
(______)______-________ |
| *Cell Phone: |
(______)______-________ |
| *Email: |
__________________________________ |
| *Emergency Contact Name (1): |
__________________________________ |
| *Emergency Contact Phone (1): |
(______)______-________ |
| *Emergency Contact Name (2): |
__________________________________ |
| *Emergency Contact Phone (2): |
(______)______-________ |
| *Authorized Pickup #1: |
__________________________________ |
| *Authorized Pickup #2: |
__________________________________ |
| Authorized Pickup #3: |
__________________________________ |
| Authorized Pickup #4: |
__________________________________ |
| I understand my student may be photographed: |
Y (circle one) |
| I understand my student's photo may be used: |
Y (circle one) |
| Comments: |
|
