Information Form 09-10 


PARTICIPANT INFORMATION 

Participant’s Full Name _________________________________________Gender_______
Home Address _____________________________________________________________ 
City ____________________________________State __________ Zip_____________
Participant’s Phone Number (H) ___________________ (C) _____________________
Participant’s Email Address ________________________________________________
Date of Birth ______/______/______
Exact Age on August 31, 2009___________________
Grade/2009-10 School Season PK K 1 2 3 4 5 6 7 8 9 10 11 12 
School Attending ___________________________________________________________ 


PARENT/GUARDIAN INFORMATION 

Mother’s Name _____________________________________________________________ 
Mother’s Phone (H)__________________(W)__________________(C)________________
Father’s Name _____________________________________________________________ 
Father’s Phone (H)___________________(W)__________________(C)________________
Parent’s Email Address (M)_________________________(F)________________________ 


MEDICAL INFORMATION 


Primary Physician ________________________________ Phone _________________
Insurance Company ______________________________ Phone _____________
Policy # _______________________________________________________________
Emergency Contact ______________________________ Phone __________________
Any Medications Allergic to or any known allergies _________________________________
List any Physical/Psychological/Prior Injuries/Current Injuries that we should be aware of: 


Joining______Credit/Debit on file? _____ Automatic Tuition? _____ Amount Paid$____________ 


T-Shirt Size YS YM YL AS AM AL AXL AXXL Shorts Size YS YM YL AS AM AL AXL AXXL 
Brief Size YS YM YL AS AM AL AXL AXXL Shoe Size__________ 
Bag__________ Make-Up Kit__________ Bow__________ Wind Suit___________