Lion Academy!

First Name*

Last Name*

Email*

Phone Number*

City and State*

Agent Name:*

Shirt Size?*

Primary Care physician : Name/ Number*

Emergency contact: Name / Number*

Do you have any current or past medical conditions?( Asthma,Diabetes, Epilepsy…)*

Have you had any recent injuries or surgeries?*

Do you require regular medical treatment or monitoring?*

Are you currently taking any medications? Please specify*

Do you have any food allergies*

Do you carry an EpiPen or other emergency medication? Please specify...*

Are you able to participate in physical activities?*

Yes

Any limitations or restrictions?*

Anything specific you'd like us to be aware of?*

Ace-Camp