Youth Health Background and Contact Form Participant's Name* First Last Gender:Date of Birth*School and Grade*Participant's Email if applicableParticipant's Cell Phone if applicableAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Phone*(###) ### - ####Name: Guardian 1*Cell Phone: Guardian 1*(###) ### - ####Email: Guardian 1* Name: Guardian 2 (optional)Cell Phone: Guardian 2 (optional)(###) ### - ####Email: Guardian 2 (optional) Emergency Contact*Emergency Contact's Relationship to Youth*Emergency Contact's Phone*(###) ### - ####Insurance Company*Policy Holder*Policy Number*Primary Care Physician*Preferred Hospital/Emergency Room*Medical HistoryCheck the following areas of concern for the participant.Does the participant have any allergies?*i.e. pollens, medications, food, insect bitesYesNoIf yes, please describe allergy/ies and treatmentsHas the participant been fully vaccinated for Covid-19? (i.e. two weeks have passed since his/her final shot)*YesNoDoes the participant suffer from, or has ever experienced, or is being treated currently for any of the following:AsthmaEpilepsy/SeizureHeart TroubleDiabetesFrequently Upset StomachPhysical HandicapMental Health Issue(s)Please explain relevant details regarding any boxes checked above and whether the participant's activities should be restricted for any reason.Is the participant regularly taking medication? If yes, please note and explain if youth director and/or chaperones need to help administer any medications.Does the participant wear glasses or contact lenses?*YesNoFor the participant's safety and our knowledge, is the participant a*Good swimmer?Fair swimmer?Non-swimmer?CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Δ
