Participant's Name
*
First Name
Last Name
Gender
*
she/her
he/him
them/they
GNB
GNC
2 Spirit
Other
DOB
*
MM
DD
YYYY
Primary driver to class
*
If primary driver is not a parent/guardian, please provide the primary driver/service information.
(###)
###
####
Assessment Notes
*
Does this participant require training programs, assessment notes or signatures from the instructor?
Registering Parent/Guardian Name
Please complete for participants 17 years old or younger.
First Name
Last Name
Mailing Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Primary phone
(###)
###
####
Parent/Guardian
Please complete information for additional parent/guardian/family
First Name
Last Name
Primary Phone
(###)
###
####
Emergency Contact
*
List an emergency contact
First Name
Last Name
Previous Injuries
*
Has the participants experienced any of the following injuries
Allergies
*
Does the participant have any allergies
Motor Challenges
*
Does participant have any challenges with motor, coordination, movement, strength, stability or muscle control?
Visual Impairments
*
Personality
*
Feel free to tell us more!!
Insurance Company
*
Policy or Certificate No.
*
Insurance Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Insurance Phone
*
(###)
###
####
Primary Care Physician (PCP)
*
PCP phone
*
(###)
###
####
Preferred Hospital/ER
*
Questions or Comments?
Media
*
TayloredFit Solutions, LLC believes in individual personal agency and ownership over images, body and self. We do ask for a release as part of our insurance protocols, however, we believe in respecting individual decisions and override this from our liability. We require your permission to display your child's image on our Facebook, Instagram, website platforms. In addition, Brown Girls Climbing/Coach Emily Taylor is currently under movie production with Pallavi Somusetty, and sponsored by several reputable and highly vetted companies. Please select any/all of the platforms you feel comfortable releasing your child's image. (Note: BGC owns IP to all images from all companies and requires final approval before print)Please check all forms of social media you consent TayloredFit Solutions to using and being used for this participant.
