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| Name of Child* |
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Date of birth* |
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| Sex* |
Male
Female |
Phone* |
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| Current address* |
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City* |
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| State* |
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Favorite driver |
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| Clothing sizes |
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Shoe size |
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| Parent Name* |
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Parent Name* |
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| Phone* |
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E-mail* |
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| Cell# |
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City |
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| ZIP Code |
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Siblings |
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| MEDICAL PROVIDER INFORMATION |
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| Physician name |
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| Address |
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City |
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| State |
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ZIP Code |
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| Medicine(s) child takes |
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| ANY LIMITATIONS OR FEARS |
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| DOES THE CHILD HAVE ANY ISSUES WITH LOUD NOISE? CLOSE QUARTERS? SUDDEN MOVEMENTS? |
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| Will you need assistance with transportation to and from scheduled events |
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| DOES CHILD REQUIRE SPECIAL ACCOMODATIONS TO TRANSPORT? IF SO PLEASE EXPLAIN |
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| HISTORY OF CHILDS MEDICAL SITUATION |
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| Briefly explain child diagnosis from Medical Providers |
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| COMMENTS/ A BRIEF STORY ABOUT YOUR CHILD |
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BY Virtual signing below you authorize an Speedway Angels representative to gather any information from medical physicians you provided within this form in consideration of an event approval. You also Understand that just by providing this information you are not Guaranteed anything from Speedway Angels Inc. more than consideration for programs they provide. If you are selected for an event a Representative will contact you by Phone we will never send you an email requesting any further information if you do receive an email that appears to be from Speedway Angels requesting any information from you do not respond and notify us right away of this activity.
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| Signature of applicant |
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Date |
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| Signature of spouse |
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Date |
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(only if for a joint membership) |
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