Yellowjackets Registration Form | Pennsylvania Cross Country Skiers Association

Child 1

Child name (First and Last)

Date of birth

Gender

Male

Female

Nonbinary

New

Yes

No

Is this child new to the Yellowjackets Program?

Level / Program

Health Insurance Information

Provider

Phone number (### ### ####)

Policy Holder's name

Policy Number

Doctor Information

Doctor or Pediatric Practice

Phone number (### ### ####)

Emergency Contact Information

Emergency Contact 1

Name (First and Last)

Main emergency contact

Relationship with child

Phone number (### ### ####)

Emergency Contact 2

Name (First and Last)

Relationship with child

Phone number (### ### ####)

Allergies

Please specify allergies and list of reactions, if applicable

Other Health or Behavioral Concerns

Please specify any other health or behavioral concerns, if applicable

Child 2

Child name (First and Last)

Date of birth

Gender

Male

Female

Nonbinary

New

Yes

No

Is this child new to the Yellowjackets Program?

Level / Program

Health Insurance Information

Same as child 1

Yes

No

Provider

Phone number (### ### ####)

Policy Holder's name

Policy Number

Doctor Information

Same as child 1

Yes

No

Doctor or Pediatric Practice

Phone number (### ### ####)

Emergency Contact Information

Same as Child 1

Yes

No

Emergency Contact 1

Name (First and Last)

Main emergency contact

Relationship with child

Phone number (### ### ####)

Emergency Contact 2

Name (First and Last)

Relationship with child

Phone number (### ### ####)

Allergies

Please specify allergies and list of reactions, if applicable

Other Health or Behavioral Concerns

Please specify any other health or behavioral concerns, if applicable

Child 3

Child name (First and Last)

Date of birth

Gender

Male

Female

Nonbinary

New

Yes

No

Is this child new to the Yellowjackets Program?

Level / Program

Health Insurance Information

Same as child 1

Yes

No

Provider

Phone number (### ### ####)

Policy Holder's name

Policy Number

Doctor Information

Same as child 1

Yes

No

Doctor or Pediatric Practice

Phone number (### ### ####)

Emergency Contact Information

Same as Child 1

Yes

No

Emergency Contact 1

Name (First and Last)

Main emergency contact

Relationship with child

Phone number (### ### ####)

Emergency Contact 2

Name (First and Last)

Relationship with child

Phone number (### ### ####)

Allergies

Please specify allergies and list of reactions, if applicable

Other Health or Behavioral Concerns

Please specify any other health or behavioral concerns, if applicable

Child 4

Child name (First and Last)

Date of birth

Gender

Male

Female

Nonbinary

New

Yes

No

Is this child new to the Yellowjackets Program?

Level / Program

Health Insurance Information

Same as child 1

Yes

No

Provider

Phone number (### ### ####)

Policy Holder's name

Policy Number

Doctor Information

Same as child 1

Yes

No

Doctor or Pediatric Practice

Phone number (### ### ####)

Emergency Contact Information

Same as Child 1

Yes

No

Emergency Contact 1

Name (First and Last)

Main emergency contact

Relationship with child

Phone number (### ### ####)

Emergency Contact 2

Name (First and Last)

Relationship with child

Phone number (### ### ####)

Allergies

Please specify allergies and list of reactions, if applicable

Other Health or Behavioral Concerns

Please specify any other health or behavioral concerns, if applicable

Child 5

Child name (First and Last)

Date of birth

Gender

Male

Female

Nonbinary

New

Yes

No

Is this child new to the Yellowjackets Program?

Level / Program

Health Insurance Information

Same as child 1

Yes

No

Provider

Phone number (### ### ####)

Policy Holder's name

Policy Number

Doctor Information

Same as child 1

Yes

No

Doctor or Pediatric Practice

Phone number (### ### ####)

Emergency Contact Information

Same as Child 1

Yes

No

Emergency Contact 1

Name (First and Last)

Main emergency contact

Relationship with child

Phone number (### ### ####)

Emergency Contact 2

Name (First and Last)

Relationship with child

Phone number (### ### ####)

Allergies

Please specify allergies and list of reactions, if applicable

Other Health or Behavioral Concerns

Please specify any other health or behavioral concerns, if applicable

Child 6

Child name (First and Last)

Date of birth

Gender

Male

Female

Nonbinary

New

Yes

No

Is this child new to the Yellowjackets Program?

Level / Program

Health Insurance Information

Same as child 1

Yes

No

Provider

Phone number (### ### ####)

Policy Holder's name

Policy Number

Doctor Information

Same as child 1

Yes

No

Doctor or Pediatric Practice

Phone number (### ### ####)

Emergency Contact Information

Same as Child 1

Yes

No

Emergency Contact 1

Name (First and Last)

Main emergency contact

Relationship with child

Phone number (### ### ####)

Emergency Contact 2

Name (First and Last)

Relationship with child

Phone number (### ### ####)

Allergies

Please specify allergies and list of reactions, if applicable

Other Health or Behavioral Concerns

Please specify any other health or behavioral concerns, if applicable