Apex Vaulters Student Information Form

Apex Vaulters Student Information Form
Vaulter Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Contact Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the vaulter under the age of 18?*

Yes, vaulter is a minorNo, vaulter is an adult
Parent/Legal Guardian
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Vaulter*
Health Information
Health Insurance Company*
Policy #*
Please list all life-threatening allergies to food, medications, insect bites/stings, etc. or write 'none' *
If an allergy is life-threatening, does the vaulter carry an epipen set (2 epipens) at all times?

YesNoNo life-threatening allergies
List any pertinent medical conditions or diagnoses (asthma, diabetes, ADHD, etc.)
List any medications the vaulter uses and indicate if daily use or as necessary
Date of last tetanus shot
Should be Empty:

Vaulter Information