The L Games

Student Health Form

Name *
Name
Home Address *
Home Address
Phone *
Phone
Parent/Guardian *
Parent/Guardian
Home Phone *
Home Phone
Father's Office
Father's Office
Mother's Office
Mother's Office
Cell Phone
Cell Phone
Neighbor/Relative who may be reached if Parent/Guardian is not available: *
Neighbor/Relative who may be reached if Parent/Guardian is not available:
Phone
Phone
Is there a Youth Corps member whom you know? *
Is the participant taking any medication? *
(If "No", enter "N/A")
Are there any physical restrictions? *
If "No", enter "N/A"
Hospital Insurance *
In Case of Emergency, Notify:
Name *
Name
Address *
Address
Phone *
Phone
Physician Phone *
Physician Phone