Primary Emergency Contact





(Check if applicable) Contact is the same as: ____Mother ____Father ____Legal Guardian



Last Name: _______________________ First Name: _______________ Middle Initial.: ______



Home Street Address: ______________________________________________________



City: ______________________ State: ______________ Zip Code: ____________



Home Phone: (____)__________________ Work Phone: (____)____________________



Cell Phone: (____)___________________ Pager: (____)_____________________



Other: (____)______________________ Email Address: ______________________________________





Alternate Emergency Contact Information (Other than Parents/Guardian)

Alternate #1





Last Name: _______________________ First Name: _______________ Middle Initial: ______



Relationship: _______________________



Home Street Address: ______________________________________________________



City: ______________________ State: ______________ Zip Code: ____________



Home Phone: (____)__________________ Work Phone: (____)____________________



Cell Phone: (____)____________________ Email Address: _____________________________________



Alternate #2





Last Name: _______________________ First Name: _______________ Middle Initial.: ______



Relationship: _______________________



Home Street Address: ______________________________________________________



City: ______________________ State: ______________ Zip Code: ____________



Home Phone: (____)__________________ Work Phone: (____)____________________



Cell Phone: (____)____________________ Email Address: _____________________________________



Medical Insurance Information (Please provide copy of front & back of medical card)





Name of Medical Insurance Company: ________________________________________



Policy Number: __________________________________________________________



Contact Telephone Number: (____)________________________



Cover Size: ___XX Small ___X Small ___Small ___Medium ___Large

T-shirt Size: ___Small ___Medium ___ Large ___X Large ___XX Large

(YMFORM2)