This is a one-time submission form.
GET A COPY OF THE RELEASE FORM HERE: Emergency Treatment Release Form
Click on the small image to download it.
Print it out, sign it and scan it.
Take a picture of the front and back of your insurance card too.
You will be required to attach the scanned files below.
Rower Date of Birth - mm/dd/yyyy
Rower Home Address
Rower Home Phone
Rower Mobile Phone
PARENT/GUARDIAN 1 INFORMATION
Parent/Guardian 1 Name (required)
Parent/Guardian 1 Email (required)
Mobile Phone Number (required)
Other Phone Number
Address (if different than Rower)
PARENT/GUARDIAN 2 INFORMATION
Parent/Guardian 2 Name
Parent/Guardian 2 Email
Mobile Phone Number
(Friend or Relative to contact when neither parent can be reached - two required)
Emergency Contact 1 Name (required)
Relationship to Student (required)
Other Phone Number
Emergency Contact 2 Name (required)
Physician Name (required)
Physician Phone Number (required)
Insurance Provider Name (required)
Policy Number (required)
Does your Rower use an inhaler?
Has your Rower been prescribed an Epipen?
Does your Rower use an contact lenses?
Does your Rower have allergies??
Is your Rower allergic to any medications?
Does your Rower have prior injuries?
If you answered "Yes" to any of the above, please provide additional details.
List any medications your Rower is currently taking.
What is the date of your child's last tetanus shot? - mm/dd/yyyy
Is there anything else we might need to know?
Emergency Treatment Release Form (required) - 5mb max file size
Medical Card Front (required) - 5mb max file size
Medical Card Back (required) - 5mb max file size
DON'T FORGET TO ATTACH YOUR FILE(s) BEFORE CLICKING SEND!
For questions about the online form, please contact the YHS Crew webmaster, Dave Underwood at firstname.lastname@example.org
For questions about the information in this form, please contact the YHS Crew registrar, Catherine Lea at email@example.com