Beach Track & Field Camp Registration - Day

Participant Full Name

Date of Birth

Sex

Male

Female

HS Graduation Year

T-Shirt Size

Select Athlete's Events

Parent / Legal Guardian Information

This Parent/Legal Guardian with legal custody will automatically be added as an emergency contact and will be notified in the event of illness or injury:

Parent or Legal Guardian Full Name

Relationship to Participant

Email

Phone Number

Address

Add a Secondary Emergency Contact (opt'l)

Secondary Contact Full Name

Relationship to Participant

Secondary Contact Email

Secondary Contact Phone Number

Participant Medical History

Has the Participant ever:

Been hospitalized?

Had surgery?

Have recurrent/chronic illness?

Had a recent infectious disease?

Had a recent injury?

Had asthma/wheezing/shortness of breath?

Have diabetes?

Had seizures?

None of the above

If yes, please explain:

Mental / Emotional History

Has the Participant ever:

Been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder?

Been treated for emotional or behavioral difficulties?

Been diagnosed with an eating disorder?

During the past 12 months, seen a professional to address mental/emotional health concerns?

Had a significant life event that continues to affect the Participant’s life? (e.g. history of abuse, death of a loved one, family change, foster care, new sibling, survived a disaster, others)

None of the above

If yes, please explain

Allergy History

Allergies

No known allergies

To foods

To medications

To the environment (e.g. insect stings, hay fever, etc)

Other allergies

Dietary restrictions

Please list checked allergens

Please describe previous reactions

Participant Injury History

Has the Participant had any orthopaedic or musculoskeletal injury the last 12 months?

Examples: muscle strains, stress injuries, fractures, joint injuries, tendon injuries

Has the Participant had any orthopaedic or musculoskeletal injury the last 12 months?

Yes

If yes, please describe

Other Health Information

Please list any additional information about the Participant’s health that you think important or that may affect the Participant’s ability to fully participate in the program

Fitness to Participate

I certify that the above information is complete and accurate. I have reviewed and understand the program description and activities of the program and believe that Participant is physically and emotionally fit to participate in the Program without restrictions or adaptations.

Waivers

By signing below, I certify that, I am the Parent/Legal Guardian of the above-named Participant or have obtained written permission from any person who is otherwise legally entitled to custody of the Participant during the Program, to the effect that the Participant may fully participate in the Program, and I agree to the Beach Track & Field Camp Liability Waiver, Media Release, and Policies.

Full Name

Electronic Signature

Signature

Beach Track & Field Camp Registration - Day

Participant Full Name

Date of Birth

Sex

HS Graduation Year

T-Shirt Size

Select Athlete's Events

Parent / Legal Guardian Information

Parent or Legal Guardian Full Name

Relationship to Participant

Email

Phone Number

Address

Add a Secondary Emergency Contact (opt'l)

Secondary Contact Full Name

Relationship to Participant

Secondary Contact Email

Secondary Contact Phone Number

Participant Medical History

Has the Participant ever:

If yes, please explain:

Mental / Emotional History

Has the Participant ever:

If yes, please explain

Allergy History

Allergies

Please list checked allergens

Please describe previous reactions

Participant Injury History

Has the Participant had any orthopaedic or musculoskeletal injury the last 12 months?

If yes, please describe

Other Health Information

Fitness to Participate

Waivers

Full Name

Electronic Signature

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