Special Dragons Registration Form

Athlete’s name: ________________________________
Male/Female (choose one):
Parent/Guardian name: ____________________________
Parent/Guardian e-mail:____________________________
Emergency contact:
Name: __________________________ Phone number: __________________________
Athlete’s date of birth: ______________________________
Address: __________________________________________
Phone numbers:
Home: ________________ Cell: _________________________
Athlete’s diagnosis, if any: _____________________________________
Conditions instructor should be aware of, including limitations regarding physical activity: _______________________________________________________________________ ______________________________________________________________________________ Name of Foundation and Case Manager _____________________________________________ Information provided by: Name: ______________________________ Signature___________________________ Date: __________