Name__________________________________________________Date of Birth___________________

Address_____________________________________________________________________________

Phone Numbers:   Home______________________ Mom’s Cell__________________

                              Dad’s Cell__________________  Work_______________________

Physician Name and Phone Number_______________________________________________________

Medical Conditions or Physical Limitations that might prevent you from fully participating

in the VYBA program?  Circle No or if Yes please circle or list:_____________________________________

Asthma    Heart Condition   Diabetes   Hypoglycemia  Seizure Disorder   Other_______________________

Learning Disabilities that might require a bit more help from the instructors?  Circle or list

Hyperactivity     ADD    Dyslexia     Other______________________________________________________

Physical Aids (Circle)   Eyeglasses    Contacts   Hearing Aids   Other:

Allergies (Circle)    Insect Bites   Bee Stings   Foods   Medicine    Other

                 Please list details if any of the above are circled_________________________________________

Date of Last Tetanus Shot______________

Parents or Legal Guardian:________________________________________________________________

    Address, if different from Child_____________________________________________________________

Emergency Phone Contact   1_________________________________Relationship___________________

   Phone (home)_______________________(cell)________________________(work)___________________

Emergency Phone Contact   2_________________________________Relationship___________________

   Phone (home)_______________________(cell)________________________(work)___________________

I,______________________, authorize the VYBA program organizers, or instructors, to approve emergency

treatment for ____________________in my absence.  It is understood that every possible effort is to be

made initially to contact me or my Emergency Contact listed above.

Signature:___________________________________________________Date:________________________

parent or guardian

***ATTACH A COPY OF YOUR MEDICAL INSURANCE CARRIER CARD***