Youth Sports Health Disclosure Consent Form
Please provide accurate health information for youth sports participation.
Participant Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Parent/Guardian Full Name
*
First Name
Last Name
Emergency Contact Number
*
Please enter a valid phone number.
Does the participant have any allergies?
*
Yes
No
If yes, please list allergies
*
Does the participant have any medical conditions?
*
Yes
No
If yes, please describe medical conditions
*
Is the participant currently taking any medications?
*
Yes
No
If yes, please list medications
*
Parent/Guardian Signature
*
Submit
Should be Empty: