Empowered Sports Fitness - Health Background Information

Name of Child(Required)

First Last

Date of Birth(Required)

Parents/Guardians(Required)

Name

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Mobile

Email(Required)

Physician(Required)

Name

Phone

Camp(Required)

Yes

Organized Sports Teams or Group Activities(Required)

Yes

General Movement and Having Fun(Required)

Yes

Emergency Contact(Required)

Name

Phone

Health Background Information