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Shred Academy

Particpant Information Form

PLEASE COMPLETE FULLY AND RESUBMIT FOR EACH CAMP IF ANY INFORMATION CHANGES. VALID FOR ONE YEAR.

First Participant's Name

First Name*

Middle Name

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Medical Information

This information will help us provide the best care for you child and will help in the event of an emergency.

Please check all that apply:
ADD/ADHD
Allergies
Asthma
Diabetes
Epilepsy
Heart disease/defect

Please list any allergies or other condition not listed above.
Does your child take and medication/prescriptions?*
No
Yes
Will your child need to be administered any medication during the program?*
No
Yes

Please list any medications and directions for administering.
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Medical Information

This information will help us provide the best care for you child and will help in the event of an emergency.

Please check all that apply:
ADD/ADHD
Allergies
Asthma
Diabetes
Epilepsy
Heart disease/defect

Please list any allergies or other condition not listed above.
Does your child take and medication/prescriptions?*
No
Yes
Will your child need to be administered any medication during the program?*
No
Yes

Please list any medications and directions for administering.
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Medical Information

This information will help us provide the best care for you child and will help in the event of an emergency.

Please check all that apply:
ADD/ADHD
Allergies
Asthma
Diabetes
Epilepsy
Heart disease/defect

Please list any allergies or other condition not listed above.
Does your child take and medication/prescriptions?*
No
Yes
Will your child need to be administered any medication during the program?*
No
Yes

Please list any medications and directions for administering.
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Medical Information

This information will help us provide the best care for you child and will help in the event of an emergency.

Please check all that apply:
ADD/ADHD
Allergies
Asthma
Diabetes
Epilepsy
Heart disease/defect

Please list any allergies or other condition not listed above.
Does your child take and medication/prescriptions?*
No
Yes
Will your child need to be administered any medication during the program?*
No
Yes

Please list any medications and directions for administering.
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Medical Information

This information will help us provide the best care for you child and will help in the event of an emergency.

Please check all that apply:
ADD/ADHD
Allergies
Asthma
Diabetes
Epilepsy
Heart disease/defect

Please list any allergies or other condition not listed above.
Does your child take and medication/prescriptions?*
No
Yes
Will your child need to be administered any medication during the program?*
No
Yes

Please list any medications and directions for administering.
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Medical Information

This information will help us provide the best care for you child and will help in the event of an emergency.

Please check all that apply:
ADD/ADHD
Allergies
Asthma
Diabetes
Epilepsy
Heart disease/defect

Please list any allergies or other condition not listed above.
Does your child take and medication/prescriptions?*
No
Yes
Will your child need to be administered any medication during the program?*
No
Yes

Please list any medications and directions for administering.
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Medical Information

This information will help us provide the best care for you child and will help in the event of an emergency.

Please check all that apply:
ADD/ADHD
Allergies
Asthma
Diabetes
Epilepsy
Heart disease/defect

Please list any allergies or other condition not listed above.
Does your child take and medication/prescriptions?*
No
Yes
Will your child need to be administered any medication during the program?*
No
Yes

Please list any medications and directions for administering.
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Medical Information

This information will help us provide the best care for you child and will help in the event of an emergency.

Please check all that apply:
ADD/ADHD
Allergies
Asthma
Diabetes
Epilepsy
Heart disease/defect

Please list any allergies or other condition not listed above.
Does your child take and medication/prescriptions?*
No
Yes
Will your child need to be administered any medication during the program?*
No
Yes

Please list any medications and directions for administering.
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Medical Information

This information will help us provide the best care for you child and will help in the event of an emergency.

Please check all that apply:
ADD/ADHD
Allergies
Asthma
Diabetes
Epilepsy
Heart disease/defect

Please list any allergies or other condition not listed above.
Does your child take and medication/prescriptions?*
No
Yes
Will your child need to be administered any medication during the program?*
No
Yes

Please list any medications and directions for administering.
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Medical Information

This information will help us provide the best care for you child and will help in the event of an emergency.

Please check all that apply:
ADD/ADHD
Allergies
Asthma
Diabetes
Epilepsy
Heart disease/defect

Please list any allergies or other condition not listed above.
Does your child take and medication/prescriptions?*
No
Yes
Will your child need to be administered any medication during the program?*
No
Yes

Please list any medications and directions for administering.
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
PICK UP/DROP OFF

Please indicate the name, relation and phone number for anyone besides yourself authorized to pick up your child (children).


Name / Relation / Phone

Name / Relation / Phone

Name / Relation / Phone


Optional code word in case of emergency alternate pick up:


Code word
Referral
How did you hear about our Programming? *

If referred, please let us know their name so we can thank them!
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Medical Information

This information will help us provide the best care for you child and will help in the event of an emergency.

Please check all that apply:
ADD/ADHD
Allergies
Asthma
Diabetes
Epilepsy
Heart disease/defect

Please list any allergies or other condition not listed above.
Does your child take and medication/prescriptions?*
No
Yes
Will your child need to be administered any medication during the program?*
No
Yes

Please list any medications and directions for administering.
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are verifying that all of the information that you have entered is correct and you are consenting to the use of your electronic signature for this document. Click below to submit. You'll receive an email confirmation with a link to confirm. <br><br> Thank you!


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