3 minutes
The student must be above 5 years and below 16 years of age.
Name
Birth Date
Grade
Gender
Address
City
State
Country
Zipcode
Parent/Guardian Information
Name:
Home Number
Cell Number
Emergency Information
Contact's Name
Relationship
Phone Number
Does the athlete have any allergies, chronic illness, or medical conditions? If yes, please describe
Is the athlete prescribed an inhaler? If yes, please explain any instructions
Signature
Signed Date