2022 Member Information Form
Dear EHSMB Families: Students & Parents, please submit the following information. Please include at least one (1) parent/guardian phone number and email address, one (1) student phone number and email address, as well as an emergency contact. Note: Please resubmit anytime your information changes. Thank you!
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Email *
Type of email *
Alternate email address
Type of email (alternate)
Clear selection
Student Last Name *
Student First Name *
Grade (Fall 2022)   *
School *
Student Birth Date *
MM
/
DD
/
YYYY
Age *
Number of years in the EHSMB (including the 2022 season) *
Phone (include area code) *
Type of phone (check all that apply) *
Required
Alternate Phone (include area code)
Type of alternate phone (check all that apply)
Address *
Parent/Guardian Name(s) *
Emergency Contact: Please include name and phone # *
Other Contact Info (Optional)
Do you know of any health factors, which make it advisable for your child to follow a limited program of physical activity or participating in any activities? If yes, please explain. Mention any recent surgery, illness, broken bones, injuries, allergies or other physical condition.
Health History
Allergies (i.e. food, etc.) List child’s allergies:
Do we have permission to administer your child:
Contact info
A copy of your responses will be emailed to the address you provided.
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