new student   registration form

Participant Name *
Participant Name
Parent/Guardian Name (If applicable)
Parent/Guardian Name (If applicable)
Phone *
Phone
Address *
Address
IN CASE OF AN EMERGENCY
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone Number *
Emergency Contact Phone Number
HEALTH INFORMATION
All information provided will be treated as strictly confidential.
Please mark any condition or injury you have or have had in the past that may impact your ability to participate in any strenuous, physical activities, but not limited to the following: *
Please include the date of injury and/or diagnosis of health condition.
If you are currently taking prescribed medications, please list below the following information.
HEALTH INSURANCE
Primary Physician Name *
Primary Physician Name
Primary Physician Number *
Primary Physician Number
Tell us about the participant's movement background, experience, fitness level, etc