Students must have health/accident insurance to attend competition.
All Information must be completed in full. Type or print clearly.
Name of Student:
Home Address:
Parents' Name(s):
In case if emergency, we must be able to contact you. Please list a home and work telephone number where you can be reached.
Father's Work Tel: ( ) Home Tel:( )
Mother's Work Tel: ( ) Home Tel:( )
Other emergency contact person:
Name: Home Tel: ( )
Work Tel:( ) Relationship:
(grandparent, neighbor, etc.)
Health/Accident Insurance Company:
Policy Number: Policy Holder:
Name of Advisor accompanying student:
Known Allergies:
(food, drugs, insects, etc.)
Special medical concerns or conditions we should know about:
(epilepsv, asthma, diabetes, old injuries to bones/joints, etc.)
Medications currently taking:
(dose and frequency)
Family Physician-
Name: Tel: Address:
Date of last tetanus booster: