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2023-2024 Health Form
Please fill out the health form below as per JRDA requirements. If you have any questions or concerns, please reach out to registration@mobcitmisfits.com. This may have duplicate information from the registration form.
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* Indicates required question
Skater Legal Name
*
Your answer
Skater Derby Name (optional)
Your answer
Parent/Guardian Name(s)
*
Your answer
Does the League Member have (Check all that apply):
*
ADD/ADHD
Allergies
Anaphylactic Allergy (please indicate in the comments below whether your skater carries an epi pen)
Asthma
Anemia
Anxiety and/or Panic Attacks
Autism Spectrum Disorder (ASD)
Bladder or Bowel Concerns
Depression
Dental Problems
Diabetes
Epilepsy Seizures
Hard of hearing or deaf
Heart Problems
History of Concussion(s) (please list in the comments below number of concussions sustained, if known)
Contacts or Glasses
Vision Considerations other than contacts or glasses
Mental Health concerns other than depression, anxiety, panic, or ASD
Other concerns coaches should be mindful of
Required
Please provide additional information for any health condition marked above. Note N/A if no health conditions are marked above.
*
Your answer
Any additional information that your want our coaches to know on how to best work with and support your skater as it relates to any health conditions.
Your answer
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