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BOULDER VALLEY PUBLIC SCHOOLS

CLUB REGISTRATION/EMERGENCY INFORMATION

Student Name _____________________________________ (M-F) Grade ______ Grad Year _______

Club(s) _____________________________________________________________________________

Parent Name _________________________________________________________________________

Address __________________________________________ City ___________________ Zip ________

Home Phone _________________________________ D.O.B. __________________ Age _________

Father’s Phone (Day) __________________________ Mother’s Phone (Day) _______________________

Father’s Phone (Cell/Pager) ___________________ Mother’s Phone (Cell/Pager) ______________________

Email address: __________________________________________________________________________

School Currently Attending ____________________________________________ Grade _________________

Name of Insurance Company: _______________________________________ Group/ID # ________________

** List two LOCAL people who will temporarily care for your student if you cannot be reached:
During The School Day

1. Name _________________________________________________ (Phone) __________________________

2. Name _________________________________________________ (Phone) __________________________


After School Hours

1. Name _________________________________________________ (Phone) __________________________

2. Name _________________________________________________ (Phone) __________________________


Family Doctor ______________________________________________ (Phone) _______________________
Address ____________________________________________________ City __________________________
Family Dentist _____________________________________________ (Phone) _______________________
Address ____________________________________________________ City __________________________

HEALTH INFORMATION: List any significant or on-going health conditions relevant to school or parkour (sever allergies / epi pen, asthma,
A.D.D., birth defect, diabetes, epilepsy, heart disease, vision or hearing problem, medications, etc.) I hereby give my consent for medical
treatment deemed necessary by physicians for any illness or injury resulting from his/her parkour participation. I understand this authorization will
only be in forced when I cannot personally be contacted and provide immediate treatment. PLEASE LIST IN THIS SPACE

___________________________________________ _____________________
(PARENT/GUARDIAN SIGNATURE) (DATE)