NAME_______________________________ DATE OF BIRTH________
AGE________ SEX___________
PARENT OR GUARDIAN__________________________________________________________________
STREET_____________________________ CITY________________ STATE_________ ZIP___________
If not available in an emergency, notify:
1) Name_______________________________________ Phone_____________________________________
Address________________________________________________________________________________
2) Name__________________________________________________________________________________
Address__________________________________________________________________________________
Family Physician_________________________________ Phone____________________________________
Address__________________________________________________________________________________
HEALTH HISTORY (Check and give approximate dates)
Ear Infections______________ Chicken
Pox___________ Allergies
Rheumatic Fever____________ Measles_______________ Hay Fever______________
Convulsions________________ Mumps________________ Penicillin_______________
Diabetes___________________ Asthma________________ Insects_________________
Do you wear contacts?________ Other __________________
Operations of Serious Injuries, Including dates:___________________________________________________
_________________________________________________________________________________________
Other Diseases or Restrictions: ________________________________________________________________
__________________________________________________________________________________________
Currently taking any medication? If so what?_____________________________________________________
_________________________________________________________________________________________
Insurance
Company__________________________________________________ Policy
#:________________
Physicians Name:______________________________________ Phone #:_____________________________
Date of last physical exam:_______________________________________
Parent/Guardian's authorization: I hereby state that to the best of my knowledge, my answers to the above questions are complete and correct. I give permission for _______________________ to participate on the Montclair YMCA Swim Team.
Parent/Guardian Signature:______________________________________ Date:________________________