Solid State Community Society
Youth Participant Medical Information Form
Youth Participant Name
*
First Name
Last Name
Personal Health Number
*
Family Doctor
Family Doctor Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact or Parent/Guardian Name
*
First Name
Last Name
Emergency Contact or Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Emergency Contact or Parent/Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Describe any medical/physical conditions that Solid State should be aware of, especially in case of emergency (i.e. epilepsy, diabetes, etc.) If there are none, please write "none".
*
Please select your current COVID-19 vaccination status.
*
Unvaccinated
Partially vaccinated (single dose)
Fully vaccinated (two doses)
Please upload a copy of your COVID-19 vaccine record or COVID-19 vaccine card. Alternatively, you may email a copy to info@solidstate.coop.
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Signature of Parent/Guardian
*
Signature of Youth Participant
*
Date
*
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