SEA Health & Emergency Contact Information
For SEA events where SEA staff or volunteers will be the primary caretakers of participants.
Attendee Information
Name of attendee
*
First Name
Last Name
Type of attendee
*
Please Select
Student
Staff
Volunteer
Other
Member Program Site
*
Please Select
Access Youth Academy
Beyond Walls
Capitol Squash
Cincinnati Squash Academy
City Squash
First State Squash
Kids On Point
MetroSquash - Evanston
MetroSquash - Woodlawn
Mission Squash
Racquet Up Detroit
Rally Portland
Santa Barbara School of Squash
SEA - NYC
Squash Haven
SquashBusters - Boston
SquashBusters - Lawrence
SquashBusters - Providence
SquashDrive
SquashSmarts
SquashWise
Steel City Squash
StreetSquash
Urban Squash Cleveland
Urban Squash Toronto
716 Squash
Select "SEA - NYC" if you are working for SEA at an event or you are not associated with an SEA member organization.
Attendee date of birth
*
-
Month
-
Day
Year
Date
Attendee's high school graduation year
*
-
Month
-
Day
Year
Date planned or completed
Attendee address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Attendee phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Attendee email (if applicable)
Gender of attendee
*
Girl / Woman
Boy / Man
Non-binary and/or Genderqueer
Gender Questioning
Other (write-in)
What are your preferred pronouns?
E.g., They/Them, She/Her, He/Him
Ethnicity of attendee
*
Hispanic or Latin(x)(o)(a)(e)
Not Hispanic or Latin(x)(o)(a)(e)
Some Other Ethnicity (write-in)
Race of attendee (select all that apply)
*
Asian / Asian American
Black / African American
Indigenous Peoples of America / Native American / Alaska Native
Middle Eastern / North African or Arab American
Native Hawaiian / Other Pacific Islander
White
Some Other Race (write-in)
Legal Guardian Emergency Contact Information
Name of legal guardian emergency contact
*
First Name
Last Name
Relationship to attendee
*
Legal guardian (emergency contact)
Phone
*
Legal guardian (emergency contact)
Format: (000) 000-0000.
Email
*
Legal guardian (emergency contact)
Program Staff Emergency Contact Information
Name of staff member emergency contact
*
First Name
Last Name
Relationship to attendee
*
Member program staff (emergency contact)
Phone
*
Member program staff (emergency contact)
Format: (000) 000-0000.
Email
Member program staff (emergency contact)
Attendee Health Information
Does the attendee have a primary care provider?
*
Yes
No
Unknown
Other (write-in)
Name of primary care provider
*
Provider's First Name
Provider's Last Name
Primary care provider clinic/office name
*
Primary care provider phone
*
Format: (000) 000-0000.
Primary care provider address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Does the attendee have health insurance?
*
Yes
No
Unknown
Other (write-in)
Health insurance provider/policy name
*
Health insurance policy/ID number
*
Group number (if applicable)
Does the attendee have any allergies, food intolerance(s) or sensitivity?
*
Yes
No
Other (write-in)
Please provide details about the attendee's allergies/food intolerance(s)/sensitivities:
*
Does the attendee have any medical conditions
*
Yes
No
Other (write-in)
Please provide details about the attendee's medical conditions:
*
Does the attendee regularly take any medication(s)?
*
Yes
No
Other (write-in)
Please provide details about the attendee's medication(s):
*
Submit
Should be Empty: