Youth Fitness Block 2
Child’s Name
First Name
Last Name
Child’s Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Any siblings attending Name, Date of birth?
Your Name
First Name
Last Name
Relationship to the child
Email Address
example@example.com
Phone Number
-
Area Code
Phone Number
Does your child/children have any medical conditions?
Is your child/children currently taking any medication? If yes, please specify.
Does your child/children have any additional support needs?
Does your child/children have any current or previous injuries that may effect participation?
Emergency Contact
First Name
Last Name
Emergency contact phone number
-
Area Code
Phone Number
Weeks attending?
Full Block
Week 1
Week 2
Week 3
Week 4
I give permission for my child to be in social media.
Yes
No
Parent agreement, please tick to confirm
I understand physical activity carries some risk.
I have informed Lauren of all relevant medical conditions.
My child is fit to participate.
I agree to notify Lauren of any changes.
I understand payment is required before first session.
Submit
Should be Empty: