GENERAL INFORMATION

Birthdate: Month _______ Day____ Year _______ 

Home Address:_______________________________________________

City: ____________________________________ Zip code: __________

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

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.) ____________

___________________________________________________________