Event Countdown
Youth Athletic Development
Child's Sign Up
Child's First Name
*
Child Last Name
*
Age
*
Date Of Birth
Parent Email
*
Parent Phone
*
Emergency Contact Name
Emergency Contact Number
PLEASE COMPLETE YOUR CHILD'S MEDICAL SHEET
Has a doctor / medical professional ever diagnosed you with a heart condition and indicated you should restrict your physical activity?
*
Yes
No
When you were not engaging in physical activity, have you experienced chest pain in the past month?
*
Yes
No
Do you ever faint or get dizzy and lose your balance?
*
Yes
No
Do you have high blood pressure or a heart condition in which a doctor / medical professional is currently prescribing a medication?
*
Yes
No
When you perform physical activity, do you feel pain in your chest?
*
Yes
No
Are you pregnant?
*
Yes
No
Do you have insulin dependent diabetes?
*
Yes
No
Do you know of any other reason you should not exercise or increase your physical activity?
*
Yes
No
*
The Information provided is accurate and to the best of my knowledge
By providing my phone number, I agree to receive text messages from the business.
SUBMIT
