Student Participant's Full Legal Name

Age

Birthdate

Mailing Address (Street, City, ZIP):

Student/Participant Phone #

School

Grade

Parent/Guardian Name

Parent/Guardian Work Phone &/or Cell Phone

Parent/Guardian(s) Email Address(es)

Covered by medical insurance? Covered by medical insurance? Yes No

Medical insurance Company Name

Policy/Group ID#

Allergies or Medical Concerns

Prescriptions or Medicines

If needed, do you authorize giving pain medicine (ex., Tylenol or Advil) to your student? If needed, do you authorize giving pain medicine (ex., Tylenol or Advil) to your student? Yes No

Name of Emergency Contact (if parent/guardian cannot be reached)

Relationship to student/participant

Emergency Conact's phone #

Please type student/participant's name as signer

Please type parent/guardian name as signer

Date