Birth date: Month _____ Day____ Year _______

Home Address:_______________________________________________

City: ____________________________________ Zip code: __________

Home Phone:_____________ Youth Cell # (if applicable): ____________

Mom's Name: _______________ Cell # _________ Work # __________

Dad's Name: ________________ Cell # _________ Work # __________

Emergency Contact Person: ____________________________________

       Relationship to Youth: ________________  Phone: _____________

Medical Authorization  

I authorize treatment for the above minor should the event leaders feel 

it is necessary.  I accept financial responsibility for any services performed.

Parent/ Guardian Name (Please Print):____________________________

Signature:___________________________________  Date: __________

Insurance Company___________________________________________

Member #  ____________________________

Other Special Instructions (Allergies, Medications, etc.) ____________

___________________________________________________________