APPLICATION/REGISTRATION FORM

NAME_________________________________________________________ DATE OF BIRTH__________________

ADDRESS_______________________________ CITY____________________ STATE_________ ZIP____________

PARENTS NAME (LEGAL GUARDIAN)_______________________________________________________________

ADDRESS_______________________________ CITY_____________________STATE__________ZIP___________

PHONE (____) ___________-_______

EMERGENCY PHONE # _________________________ CONTACT NAME____________________________________

INSURANCE CO.___________________________________________ POLICY # ______________________________

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HEALTH INFORMATION (CIRCLE THOSE APPROPRIATE)

Down Syndrome Atlanto-axial Instability Diabetes

Heart Problems Seizure Disorder Visually Impaired

Hearing Impaired Fainting Spells Non-verbal Signs

Hepatitis Bleeding Problems Mobility Impairment

Asthma Emotional Problems Learning Disabilities

Allergies High Blood Pressure Low Blood Pressure

OTHERS: please list:

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LIST AIDS USED (such as a wheel chair, hearing aid, glasses, etc.)

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LIST ALLERGIES:

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MEDICATIONS:

NAME: DOSAGE: TIME GIVEN: SIDE EFFECTS

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IMMUNIZATIONS:

DATE OF LAST SHOT

TETANUS __________________________

POLIO __________________________

HEPATITIS B __________________________

LIST ANY OTHER INFORMATION THAT THE COACHING STAFF NEEDS TO KNOW ABOUT YOUR CHILD.

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