Hale Mountain Bike Club Health History
INFORMATION
Child's First Name
MI
Last Name
Skill level and interest
Beginner MTB
Intermediate MTB
Advanced MTB
Interested in some racing
Just want to ride bikes
Date of Birth
Address
Street
City
State
Zip
Gender
Please select...
Male
Female
Gender Fluid or Non-Binary
Prefer Not to Say
Participant Shirt Sizes
Youth Shirt Sizes
Youth Small
Youth Medium
Youth Large
Adult Shirt Sizes
Small
Medium
Large
PRIMARY GUARDIAN INFORMATION
Primary Guardian First Name
Last Name
Phone
Email
SECONDARY GUARDIAN INFORMATION
Secondary Guardian First Name
Last Name
Phone
Email
EMERGENCY CONTACT INFORMATION
First Name
Last Name
Phone
Relationship to participant
EMERGENCY CONTACT #2
First Name
Last Name
Phone
Relationship to participant
Authorized Pick-Up Information
Hale only releases participants to adults that are authorized by Primary Caregivers. Please list all of the authorized individuals that may pick up your from this activity.
Authorized Pick Up Information #1
First Name
Last Name
Phone Number
Relation to Camper
Additional Authorized Pick Up Information
First Name
Last Name
Phone Number
Relation to Camper
PHYSICIAN INFORMATION
Please enter the name of your child's Physician:
Please enter the Phone Number for the Physician:
HEALTH INSURANCE INFORMATIO
N
Insurance Carrier
Policy Holder Name
Policy/Group Number
MEDICAL HISTORY
Does your child have asthma?
Yes
No
Does your child have diabetes?
Yes
No
Have a seizure disorder?
Yes
No
Recurrent or Chronic Illness?
Yes
No
Been hospitalized in the last 2 years?
Yes
No
Had a head injury or concusion?
Yes
No
Have severe or frequent headaches?
Yes
No
Has experienced dizziness or fainting?
Yes
No
Have frequent bloody noses?
Yes
No
Ever been stung by a bee?
Yes
No
Ever have back or joint problems?
Yes
No
Have stomach or intestinal issues?
Yes
No
If applicable, have problems with menstration?
Yes
No
Not Applicable
MENTAL HEALTH HISTORY
Has your child ever been treated for ADD/ADHD?
Yes
No
Has your child ever been treated for emotional/behavioral difficulties, self-harm or an eating disorder?
Yes
No
Has your child ever needed the support of an aide at school?
Yes
No
During the past year has your child seen a professional to support mental/emotional health concerns?
Yes
No
Does your child have an IEP at school?
Yes
No
Has your child had any major life events happen in the last year?
Yes
No
Is there any additional information that you'd like us to know about your child?
ALLERGIES
Does your child have any allergies?
No
Yes, seasonal/environmental
Yes, food allergies
Yes, medication allergy
Please let us know of the specific allergies:
DIET AND NUTRITION
Let us know about your child's dietary needs:
No dietary restrictions
Vegetarian/Vegan
Gluten-Free Diet
RESTRICTIONS
Does your rider have any restrictions related to participating in any club activities?
Yes
No
Please share what restrictions your rider may have so we can work on making accommodations.
On the next page, please enter your signature and information. You will then be asked to verify your signature by opening the verification email and following the directions it contains. Please do not skip this step!
HMBC Health History/Contact Form