TAASC Registration Form
Fill out this form to join one of our programs
Name and Contact Info
Name of student
*
First Name
Last Name
Current Age
*
Date of birth
*
School you attend
*
Parent Name
*
First Name
Last Name
Parent Name
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
E-mail (other)
Phone Number
*
-
Area Code
Phone Number
Name of emergency contact
*
First Name
Last Name
Relationship of emergency contact
*
Phone of emergency contact
*
-
Area Code
Phone Number
TAASC Program Options
Group you are signing up for:
*
Saplings Girls Group (6 -7)
Oak Girls Group (8 - 10)
Redwood Girls Group (11 - 14)
Foxes Boys Group (8 - 11), meets on Wed
Wolves Boys Group (8 - 11)
Coyote Middle School Boys (11 - 13), meets on Tues
Dogwoods Teen Group (14 - 18)
TAASC Informed Consent-Liability Release
By checking box below and typing your name in lieu of your signature, you are consenting to the information in our waiver form (you need to scroll below & view full Release). If the participant is under 18 their parent or guardian must sign.
Name
*
First Name
Last Name
Medical Information
This is used to assess participants health and to help us take care of them best. Please put n/a if not applicable
Allergies - list all
*
Reaction to Allergies
*
Allergy Medications required
*
Any Medications currently taken
*
Health Profile (check all that apply)
*
Hospitalization/ER visit in past year
Current orthopaedic problems
Diagnosed learning disability and or ADD/ADHD
Other medical issues/illnesses/symptoms/requirements
Asthma - if yes please provide own inhaler
None
Description of any you checked above
Personal History
Based upon past 12 months
Have you been diagnosed or treated for any of the following in past year
*
ADD (attention deficit disorder)
Anxiety disorder
Disruptive behavior
Eating disorder
Impulse control disorder
Other
None
Have you experienced any of the following significant events within the past year?
*
Serious Illness
Serious accident/injury
Self harm
Death of family/friend
None
If you answered Yes to any of the above 2 questions - please explain
Any other pertinent information you'd like us to know. (This will help us best serve your child)
Insurance Information
Participants are responsible for any medical expenses and should be covered by their own illness and accident insurance.
Name of Insurance company
*
Your Policy number
*
Medical Confidentiality and Consent
By typing my name below and checking box, in lieu of my signature I am consenting to the information below. Scroll below to view in full. If the participant is under 18, their parent or guardian must sign below.
Name
*
First Name
Last Name
Photography and Testimonial Release
By checking box I am consenting to information below
Sign Up!
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