TRAK Membership Registration

Membership
Parent/ Primary Adult Contact*

First NameLast Name
Child or Youth Participant*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Additional Child or Youth Participant

First NameLast Name
Date of Birth

MonthDayYear
Required for each child
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number:*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Email (@arizona emails are not accepted)*
No U of A email please (@arizona.edu) their servers block us
Parent/ Second Adult Contact

First NameLast Name
Type a question
E-mail
Phone Number

Area CodePhone Number
YesNo
Occupational Affiliations (Optional):
Special Skills (Optional):
Special Notes for Staff to Consider
Emergency Contact #1*

First NameLast Name
Emergency Phone Number #1*

Area CodePhone Number
Alternative Emergency Contact #2

First NameLast Name
Emergency Phone Number #2

Area CodePhone Number

Medical Information

Insurance information is required
Hospital/Clinic Preference
Physician's Name*
Physician's Phone Number*

Area CodePhone Number
Insurance Company*
You MUST have Insurance to participate
Policy Number*
You MUST have Insurance to participate
NutsGlutenCaseinSoyLactose intoleranceHay/Seasonal/EnvironmentalOther
Allergies (any details you wish to add)
Does your child take medication? If so, what, and how often? Do any of the medications impact balance or judgment?*
Write N/A if not applicable to your registration.
Are there any behavioral patterns or concerns we should know about?*
Anything else that we should know about you or your child?
What goals do you have for your child?*
For Minor Child:
If parents are divorced, who has custody?
If yes, please let us know who is the responsible party for TRAK invoices?
Anything else regarding child guardianship?
Whom may we thank for your referral?
Where did you hear about TRAK?*

Medical Information