2018 Mini & Junior Games Registration

We look forward to you joining us in Baltimore on Sunday, May 6 for the first ever combined Mini & Junior Games. Kindly complete every question on this form in order to register for the program.

Participant Name Participant Name First Last
Participant Birthdate Participant Birthdate / MM / DD YYYY
Name of JCC Delegation
Select Program
Sport Participating In
Lunch Preference

Please select your preferred lunch item
Jersey T shirt size

Please select one size
Please indicate any dietary restrictions or food allergies
Emergency Contact/ Parent/Guardian Emergency Contact/ Parent/Guardian First Last
Parent/Guardian email
Emergency Contact Phone Emergency Contact Phone - ### - ### ####
Current Medications
Health History

Health History Bleeding Clotting Disorders Diabetes Frequent Ear Infections Prophylaxis Heart Defect/Disease Seizure/Fainting Tetanus Injection Other Please indicate other: Please indicate other:
Are you under any restrictions by a health care provider?

Are you under any restrictions by a health care provider? Yes No If yes, Please explain If yes, Please explain
Do you have any medical conditions that the JCC should be aware of in case of emergency?

Do you have any medical conditions that the JCC should be aware of in case of emergency? No Yes If yes, please explain: If yes, please explain:
Do you have any of the following allergies?

Do you have any of the following allergies? Asthma Penicillin Insect Stings Food Please specify food allergies: Please specify food allergies:
Medical/ Hospital Insurance Information
Name of Holder
Carrier:
Phone on insurance:
Policy / Group #:
Emergency Authorization: In the event I cannot be reached in an emergency, the underwritten parent/guardian gives permission to the physician selected by the leaders of the JCC of Greater Baltimore to hospitalize, secure proper treatment for, to order injection and/or anesthesia or surgery for my child, as name in the application. I understand the JCC of Greater Baltimore is not liable for personal or family medical plan including hospitalization, before they participate in this program. We certify that the participant names above have such a plan.

Emergency Authorization: In the event I cannot be reached in an emergency, the underwritten parent/guardian gives permission to the physician selected by the leaders of the JCC of Greater Baltimore to hospitalize, secure proper treatment for, to order injection and/or anesthesia or surgery for my child, as name in the application. I understand the JCC of Greater Baltimore is not liable for personal or family medical plan including hospitalization, before they participate in this program. We certify that the participant names above have such a plan. I give my consent
Parent/Guardian Name for Emergency Authorization Parent/Guardian Name for Emergency Authorization First Last
Today's Date Today's Date / MM / DD YYYY
If I cannot be reached, please contact:
Cell phone for alternate contact Cell phone for alternate contact - ### - ### ####

2018 Mini & Junior Games Registration

2018 Mini & Junior Games Registration

Medical/ Hospital Insurance Information