Full Name (Participant Information) *

Address (Street, City, State, Zip) *

Date of Birth *

Age *

School Grade *

Email *

Phone *

Mother Name (Parent Contact Information) *

Address (If different from participant) *

Email *

Phone *

Father Name (Parent Contact Information) *

Address (If different from participant) *

Email *

Phone *

Name (Emergency Contact Information) *

Address *

Relationship *

Email *

Phone *

Doctor’s Name *

Phone *

Does participant have any medical condition that inhibits or preclude them from participating in physical or sports activities? If so, please explain. *

Does participant currently suffer from any type of respiratory ailment, such as asthma or emphysema? If yes, please explain. *