Jr./Sr. High Medical Information 2021

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Participant's Name

*

Birthdate

*

Gender

*

Please select one option.

Male Female

Youth Cell Phone

Address

*

Home Phone

Parent/Guardian's Name

*

Cell Phone

*

Second Parent or Emergency Contact's Name

Relationship to Participant

Cell Phone

Address (if different)

Health Plan Carrier

*

Name of Insured

*

Relationship to Participant

*

Policy Holder/Insurance ID #

*

Family Doctor

Office Phone

Please copy or photograph Medical Card (front) and upload

*

Upload (8MB)

Please copy or photograph Medical Card (back) and upload

Upload (8MB)

Does Participant have ...

*

Please select all that apply.

Allergies (if yes, see next section) Diabetes Sight or Hearing Impairment Heart Condition Other? None

If yes, please explain

Does Participant have a reaction to...

*

Please select all that apply.

Bee Stings Dairy Eggs Nuts Other None

If yes, please explain.

Is Participant subject to ...

*

Please select all that apply.

Headaches Fainting Motion Sickness Seizures Upset Stomach Other None

If yes, please explain

Description

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Please Fix the Following

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