Student/Athlete’s Name: ________________________________________Gender: ______ Grade: ________

    Address: ___________________________________City: __________________ State: ______ Zip: _______
                                                                                           
    DOB: ____/____/____         Race: ____________________ School: _______________________________         

    Allergies: __________________________, _______________________________, ______________________

    Medications: _______________________, _____________________________, ________________________

                               Circle One                      Circle One
    T-Shirt Size:        Adult / Youth                S    M    L    XL    2X    3X


    Mother/Guardian Name: __________________________________________ Phone#: _________________

    Email: __________________________________________________

    Father/Guardian Name: ___________________________________________ Phone#: _________________

    Email: __________________________________________________


    Emergency Contact Information:

    Name: ____________________________________Phone#: _________________ Relationship: ____________

    Name of Family Hospital Plan: _____________________________ Plan#: ____________________________

    Name of Primary Care Physician: ___________________________ Phone#: __________________________


    Student Athlete Signature: _______________________________________________ Date: __________

    Parent/Guardian Signature: _______________________________________________ Date: __________
    (Required under 18 years of age)

                                                                                                                                   
    Comments: