Activity Participation Form

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Full Name: *
Please type your full name.
Birth Date: *
Please type your birth date.
Check One: *
Please check one of the options.
Under 18? *
Choose yes or no.
If Yes Name of Parent/Guardian: *
Please type your full name.
Address: *
Please type your address.
City: *
Please type your city.
State: *
Please choose your state.
Zip Code: *
Please type your zip code.
Home Phone Number: *
Please type your home phone.
Work Phone Number: *
Please type your work phone.
Email: *
Please type your email.
Person to contact in case of emergency (not parent/guardian)
Name: *
Please type a name.
Street Address: *
Please type an address.
City: *
Please type city.
State: *
Please select state.
Zip Code: *
Invalid Input
Home Phone Number: *
Please type a home phone.
Work Phone Number: *
Please type a work phone.
CURRENT MEDICAL INFORMATION
Allergies (including food):
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Illnesses/Injuries:
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Special Physical Concerns:
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Medications:
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In case parent/guardian or emergency contact cannot be notified immediately do you authorize a leader to administer any of the following:
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Name of Health Insurance Company:
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Name of Person Insured:
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Social Security Number:
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Policy Number:
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Group Number:
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Insurance Company Phone Number:
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Address:
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City:
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State:
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Zip Code:
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Please make sure parent/guardian is present to sign participation agreement form. It is helpful to bring a photocopy of your insurance card.
Please type the letters below. Please type the letters below.
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