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Youth Medical/Information Sheet

Today's Date: May 24, 2022

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Medical Information

Health/Allergies/Medications. Anything you think we might need to know about your child's health:

Special Considerations/helpful info about your child. (Lead instructor will also be available for in person discussions regarding any sensitive material, but any information you can include here is appreciated):
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

Health/Allergies/Medications. Anything you think we might need to know about your child's health:

Special Considerations/helpful info about your child. (Lead instructor will also be available for in person discussions regarding any sensitive material, but any information you can include here is appreciated):
Third Participant's Name

First Name*

Middle Name

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

Health/Allergies/Medications. Anything you think we might need to know about your child's health:

Special Considerations/helpful info about your child. (Lead instructor will also be available for in person discussions regarding any sensitive material, but any information you can include here is appreciated):
Fourth Participant's Name

First Name*

Middle Name

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

Health/Allergies/Medications. Anything you think we might need to know about your child's health:

Special Considerations/helpful info about your child. (Lead instructor will also be available for in person discussions regarding any sensitive material, but any information you can include here is appreciated):
Fifth Participant's Name

First Name*

Middle Name

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

Health/Allergies/Medications. Anything you think we might need to know about your child's health:

Special Considerations/helpful info about your child. (Lead instructor will also be available for in person discussions regarding any sensitive material, but any information you can include here is appreciated):
Sixth Participant's Name

First Name*

Middle Name

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

Health/Allergies/Medications. Anything you think we might need to know about your child's health:

Special Considerations/helpful info about your child. (Lead instructor will also be available for in person discussions regarding any sensitive material, but any information you can include here is appreciated):
Seventh Participant's Name

First Name*

Middle Name

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

Health/Allergies/Medications. Anything you think we might need to know about your child's health:

Special Considerations/helpful info about your child. (Lead instructor will also be available for in person discussions regarding any sensitive material, but any information you can include here is appreciated):
Eighth Participant's Name

First Name*

Middle Name

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

Health/Allergies/Medications. Anything you think we might need to know about your child's health:

Special Considerations/helpful info about your child. (Lead instructor will also be available for in person discussions regarding any sensitive material, but any information you can include here is appreciated):
Ninth Participant's Name

First Name*

Middle Name

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

Health/Allergies/Medications. Anything you think we might need to know about your child's health:

Special Considerations/helpful info about your child. (Lead instructor will also be available for in person discussions regarding any sensitive material, but any information you can include here is appreciated):
Tenth Participant's Name

First Name*

Middle Name

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

Health/Allergies/Medications. Anything you think we might need to know about your child's health:

Special Considerations/helpful info about your child. (Lead instructor will also be available for in person discussions regarding any sensitive material, but any information you can include here is appreciated):
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contacts & Pick-Up List

Emergency Contact #1


Emergency Contact #1 First and Last Name *

Emergency Contact #1 Phone Number *

Emergency Contact #1 Relationship to Childe(ren) *

Emergency Contact #2


Emergency Contact #2 First and Last Name

Emergency Contact #2 Phone Number

Emergency Contact #2 Relationship to Child(ren)

Other people on the pick-up list

Name, phone number, and relationship to youth.

Note: Youth in our program will not be allowed to leave HMB without someone on this list. If you are on the emergency contact section, you do not need to re-enter your information. If youth is allowed to check themselves out, please indicate that here:
Additional Information

How did you find out about our Pebble Apprentice Program? We are trying to increase enrollment and need to know what is working and what isn't?
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*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Medical Information

Health/Allergies/Medications. Anything you think we might need to know about your child's health:

Special Considerations/helpful info about your child. (Lead instructor will also be available for in person discussions regarding any sensitive material, but any information you can include here is appreciated):
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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