DOF Youth Participation Form

DESERT OF FLORIDA

DESERT CONFERENCE / GALA DAY
PARTICIPATION AND MEDICAL AUTHORIZATION FORM
Please print or type. Note: This PDF form is fillable.

Check this box if the youth is an Associate Member i.e., not a full member of a local youth club
Date*
Convention City*
Temple/Court Name*
Temple/Court City*
Youth’s Name*
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Address*

Youth Street Address

Street Address Line 2

CityState

Zip
Parent/Guardian Name*
Phone*
Address if different than youth
Physician Name
Physician Phone
Dentist Name
Dentist Phone
MEDICAL HISTORY
1. Has this youth ever had hospitalizations, injury, or serious medical illness?*

YesNo
2. Is this youth now under the care of a physician or taking any medication?*

YesNo
3. Has any physician ever recommended, or do you feel that there should be limits placed on participation in competitive sports?*

YesNo
4. Does this youth have any known allergies to medication?*

YesNo
5. Does this youth wear glasses or contact lenses?*

YesNo
5.2 Give date of last exam, if glasses or contacts are worn

MonthDayYear
Date
6. Has this youth ever blacked out or lost consciousness during physical activity?*

YesNo
7. Has the child had a physical examination by a medical provider in the last six months?*

YesNo
7.2 If yes, list the of last physical examination

MonthDayYear
Date
7.3 If Yes to any of the above, please specify
8. Allergies/Special Health Considerations
PHOTO RELEASE*

I grant the Youth Club/Conference agents/staff or affiliates the right to take photographs of my child. I agree that the aforementioned may use such photographs of my child for any lawful purpose, including for example such purposes as publicity, illustration, advertising, social media, and website content.I do not grant the Youth Club/Conference agents/staff or affiliates the right to take photographs of my child.
I consent to the participation of the above-named youth in the activities and conferences of His/Her youth group, including practice sessions and travel to and from athletics and other activities. I also agree to emergency medical treatment as deemed necessary by the physicians designated by the proper authorities.
Youth Name*
Parent/Gaurdian Signature*

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PARTICIPATION AND MEDICAL AUTHORIZATION FORM

MEDICAL HISTORY