| *Participant's First Name: |
__________________________________ |
| *Participant's Last Name: |
__________________________________ |
| *Gender: |
Male Female (circle one) |
| *Last Grade Completed: |
__________________________________ |
| *Birthday: |
__________________________________ |
| *Parent/Guardian Name: |
__________________________________ |
| *Address: |
__________________________________ |
| *City: |
__________________________________ |
| *State: |
__________________________________ |
| *Zip: |
__________________________________ |
| Primary Phone: |
(______)______-________ |
| Work Phone: |
(______)______-________ |
| *Cell Phone: |
(______)______-________ |
| Email: |
__________________________________ |
| *Medical Insurance Co.: |
__________________________________ |
| *Group Number: |
__________________________________ |
| *Policy Number: |
__________________________________ |
| *Insurance Co Address: |
__________________________________ |
| *Insurance Co City: |
__________________________________ |
| *Insurance Co State: |
__________________________________ |
| *Insurance Co Zip: |
__________________________________ |
| *Insurance Co Phone: |
(______)______-________ |
| *Physicians Name: |
__________________________________ |
| *Physicians Phone: |
(______)______-________ |
| *Allergies, Medical, & Special Needs: |
|
| *Medication: |
|
| *Operations and Injuries: |
|
| *Emergency Authorization: |
Y N (circle one) |
| *Financial Responsibility: |
Y N (circle one) |
| *Emergency Contact Name (1): |
__________________________________ |
| *Relationship: |
__________________________________ |
| *Emergency Contact Phone (1): |
(______)______-________ |
| Emergency Contact Name (2): |
__________________________________ |
| Emergency Contact Phone (2): |
(______)______-________ |
| *Authorized Pickup #1: |
__________________________________ |
| Authorized Pickup #2: |
__________________________________ |
| Authorized Pickup #3: |
__________________________________ |
| Authorized Pickup #4: |
__________________________________ |
| Are you a member of this church?: |
Yes No (circle one) |
| Do you attend Church?: |
Yes No (circle one) |
| If so, where?: |
__________________________________ |
| May we have permission to photograph your child?: |
Yes No (circle one) |
| May we have permission to use your child's photograph in church publications?: |
Yes No (circle one) |
| T-Shirt Size: |
__________________________________ |
