Health Background Information Health Background Information Step 1 of 3 33% BACKGROUND INFORMATIONName of Child(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Parents/Guardians(Required) Add RemoveNameAddress(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)MobileEmail(Required) Physician(Required)NamePhoneGOALS FOR YOUR CHILDCamp(Required) Yes No Organized Sports Teams or Group Activities(Required) Yes No General Movement and Having Fun(Required) Yes No EMERGENCY CONTACTEmergency Contact(Required)NamePhone Add Remove PAST AND PRESENT MEDICAL HISTORYHeart Condition(Required) Yes No Diabetes Type I(Required) Yes No Diabetes Type II(Required) Yes No High Cholesterol(Required) Yes No Asthma or breathing difficulties: (yes/no) Fainting or dizzy spells(Required) Yes No High blood pressure: (yes/no) Epilepsy or seizures: (yes/no) Allergies(Required) Yes No Other INJURIES OR SURGERIESMuscle injury in the last 12 months (ie: tear or sprain)(Required) Yes No Surgery in the last 24 months(Required) Yes No Joint pain or Broken Bones in the last 12 months(Required) Yes No Other MEDICATIONSVision(Required) Yes No Motor skills(Required) Yes No Hearing(Required) Yes No Balance(Required) Yes No Speech/comprehension(Required) Yes No Other learning difficulties or special needs(Required) Yes No Other MEDICATIONSDoes your child currently participate in sports or physical activity at school or within a club(Required) Yes No Is there any reason preventing or affecting your child’s participation in physical activity(Required) Yes No Has your child been recommended by a health professional to participate in physical activity(Required) Yes No Other INFORMED CONSENTI herby acknowledge that:The information provided above regarding my child’s health is, to the best of my knowledge, and correct(Required) Yes No I will inform you immediately if there are any changes to the information provided above(Required) Yes No I give permission for my child to participate in Empowered Sports & Fitness activities(Required) Yes No I acknowledge that participating in physical activity for my child carries a risk and I accept all responsibility for that risk:Parent/Guardian(Required) First Last
