Youth Participant Registration Form

Youth Participant Registration Form
Participant Information
Participant Name*

First NameLast Name
Birthday*

MonthDayYear
Date
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Name*
Grade*
Parent Information
Parent/Guardian #1*

First NameLast Name
Parent/Guardian #1 Phone Number*
Please enter a valid phone number.
Parent/Guardian #1 Email *
example@example.com
Parent/Guardian #2

First NameLast Name
Parent/Guardian #2 Phone Number
Please enter a valid phone number.
Parent/Guardian #2 Email
example@example.com
Emergency Contact (other than parent)*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Medical Information
Name of Doctor
Office Phone Number
Please enter a valid phone number.
Insurance Carrier
Policy Number
Name of Dentist
Office Phone Number
Please enter a valid phone number.
Please list any of the following: medical conditions, current medications, medication allergies, food allergies, or chronic health concerns, physical challenges, behavioral considerations, or any other considerations that we should be aware of. (if none, please write N/A)*
Safety Policy

Please read and sign below
Our primary concern is the Participants’ safety. We will teach and expect all Participants to follow all safety rules. If a Participant does not follow safety rules for any reason, they will be asked to sit out. If this is a recurring situation and the Participant is not adhering to safety protocol, we reserve the right to remove the Participant from the session and bar the Participant from future participation.
Participant Name*

First NameLast Name
Participant Signature (if over 18 years of age)

Clear
Date

MonthDayYear
Date
If Participant is under 18 years of age, parent or legal guardian must sign on behalf of Participant
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

Youth Participant Registration Form

Participant Information

Parent Information

Medical Information

Safety Policy