STUDENT’S NAME:
Last First M.I.

Date of Birth

Sex (M or F)

Address

City

State

Zip

Email

Physical handicaps
(Specify missing or injured body parts, weaknesses, eyeglass, contacts,hearing, learning disabilities)

Bones and joints

Muscles

Organs

Weight problem

Other

Physiological Handicaps
(Specify problem areas such as anxieties, fears, hyperactivity, hypersensitivity)

Asthma, or other respiratory problems

Circulatory or heart problems

Diabetes or hypoglycemia

Epilepsy

Hemophilia, or other bleeding problems

Allergies

Insect bites

Bee Stings

Foods

Other, if significant
(including drugs/medication)

Other Information

Blood type

Current medication and dosages

Date of last Tetanus shot

Preferred Personal or Family Physician

Name

Phone

Health Insurance (required)

Name

Phone

Parent(s) / Guardian(s)

1. Name

Relationship

Phone

2. Name

Relationship

Phone

3. Name

Relationship

Parent/Guardian Emergency Treatment Authorization:

I, (Parent of Guardian), authorize the Program organizers or their employees to sanction emergency treatment if none of the above names (1, 2, or 3) can be contacted at the time of the emergency.

Signature

Date

Emergency phone for parent/guardian

Home Phone

Business Phone

Lake Phone

IMPORTANT: This form must be completed in its entirety for registration to be fully processed.

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