One moment please...
Youth Participant Health and Medical History 2022
Contact Information
*

First Name
Last Name
*


*

(mm/dd/yyyy)
*

Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
*

A pronoun is a word that refers to either the people talking (“I” or “you”) or someone or something that is being talked about (like “she”, “it”, “them”, and “this”). Gender pronouns (he/she/they/ze etc.) specifically refer to the person you are referring to.

*

*

First Name
Last Name
*

*

*

A pronoun is a word that refers to either the people talking (“I” or “you”) or someone or something that is being talked about (like “she”, “it”, “them”, and “this”). Gender pronouns (he/she/they/ze etc.) specifically refer to the person you are referring to.
Emergency Contact Information
at least one contact must be locally available, quickly and easily reachable by phone, and able to retrieve the participant during the course of the program
*

First Name
Last Name
*


Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
*



First Name
Last Name


Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country


Physician/Clinic Information
MEDICAL AUTHORIZATION - SIGNATURE REQUIRED
*

*

Insurance
Each Student is responsible for medical costs. Sickness and accident insurance is recommended but not required.
*



Medical History
*

(mm/dd/yyyy)
*







Any necessary medication must be in its original prescription container with a clear label detailing student's name, doctor's name & dosage instructions. * If yes, youth must have applicable medication in a clearly labeled prescription container with patient's name on it.
Accessibility




These could look like hand powered cycles, recumbent/recliner style bikes, tandem bikes where you could co-ride with a staff member and take breaks when needed, and tandem bikes that provide bodily support for participants who utilize wheelchairs.

Exercise

Check one for each

*
*
*
*
We will not be swimming during 2022 summer camps.
*
MEDICAL AUTHORIZATION

SIGNATURE BELOW REQUIRED

In case of emergency, I hereby authorize and give permission to any physician, hospital, health care provider, or other medical personell selected by the staff of Bike Works to provide prompt medical treatment and arrange necessary related transportation for the participant. I agree that once the participant is in the care of medical personell or a medical facility, Bike Works shall have no further responsibility for the participant and I agree to pay all costs associated with such medical care and transportation. This completed form will be photocopied for the files of Bike Works. 

The health history on this form is correct and not falsified to the best of our knowledge. I agree to allow Bike Works staff to dispense medications to the participant. 

*

*