Youth Sports Medical Intake Form
Please complete this form to provide essential medical and emergency information for safe participation in youth sports activities.
Athlete's Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name (other than parent/guardian)
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Does the athlete have any allergies?
*
No
Yes (please specify below)
Please list all allergies (if any)
Does the athlete take any medications regularly?
*
No
Yes (please specify below)
Please list all current medications (if any)
Does the athlete have any chronic medical conditions or past injuries?
*
No
Yes (please specify below)
Please describe any chronic conditions or past injuries (if any)
Primary Care Physician Name
First Name
Last Name
Physician Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Insurance Provider
Medical Insurance Policy Number (last 4 digits only)
Are there any restrictions or special instructions for this athlete's participation?
Parent/Guardian Signature
*
Submit Medical Intake
Submit Medical Intake
Should be Empty: