Kid'S Climbing Registration Form printable pdf download

REGISTRATION FORM

Last Name: _____________________________________ First Name_______________________

Parent or Guardian_______________________________ Phone:__________________________

Name of Doctor:____________________ Doctor’s phone number___________________________

Name of Dentist:______________________ Dentist’s phone number:_______________________

Health Insurance and number: _______________________________________________________

ALLERGIES: _____________________________________________________________________

________________________________________________________________________________

DIETARY RESTRICTIONS ___________________________________________________________

________________________________________________________________________________

MEDICAL HISTORY (Please check if your child has, or has had, any of the following conditions)

____ Hospitalized ____ Diabetes ____ Stroke

____ Head injuries

____ Seizures

____ Epilepsy

____ Headaches or fainting ____ Vision Problems

____ Asthma or respiratory

____ Hearing Problems ____ Had a recent injury ____ Recent illness

____ Hepatitis

____ Aids

____ Hypoglycemia

____ Abdominal pain/problem ____ Mental Illness ____ Altitude sickness

____ Skin problems/reactions

____ Other

IF YOU CHECKED ANY OF THE ABOVE CONDITIONS, PLEASE PROVIDE FURTHER EXPLANATION:

________________________________________________________________________________

Medication taken outside of ABC_____________________Reason___________________________

Medication to be taken at ABC ____________________________ Reason_____________________

Medication must be in original containers and accompanied by Medication Administration Form(s)

signed by you and your doctor indicating time and dosage.

Kid'S Climbing Registration Form