Name *

Athlete

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Parent or Guardian *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you seen a doctor in the past year for any medical problems? *

Yes

No

In the past year, have you required any taping, wrapping, or bracing for participation in athletics? *

Yes

No

Have you ever experienced chest pain, "racing heart", irregular heartbeat, difficulties breathing or catching your breath while exercising or playing a sport? *

Yes

No

Have you ever experienced nausea, dizziness, severe cramping or fainting from heat which forced you to stop the activity? *

Yes

No

Have you ever passed out during a sport activity/exercise or lost consciousness due to a head injury? *

Yes

No

Have you ever had sports induced asthma? *

Yes

No

Do you have diabetes? *

Yes

No

Have you ever had shin splints? *

Yes

No

Has anyone in your family had a history of heart disease or stroke before the age of 50? *

Yes

No

Have you pulled or strained a muscle within the past year? *

Yes

No

Are you currently taking any medication? *

Yes

No

Is there any condition that might limit your participation in this program? *

Yes

No

In the past 3 years, have you had any injuries, surgeries or problems with the following areas? *

Low Back

Neck

Ankle

Knee

Shoulder

None of the above

Are you currently involved in a strength program? *

Yes

No

Have you had a physical in the past year? *

Yes

No

Are you a current member of the YMCA? (Not required to participate in Architech Sports Programs) *

Yes

No