APPLICANT INFORMATION
Name of Child*
Date of birth
Sex
Phone
Current address
City
State
Favorite driver
Clothing sizes
Shoe size
FAMILY INFORMATION
Parent Name
Cell#
ZIP Code
Siblings
MEDICAL PROVIDER INFORMATION
Physician name
Address
Medicine(s) child takes
ANY LIMITATIONS OR FEARS
DOES THE CHILD HAVE ANY ISSUES WITH LOUD NOISE? CLOSE QUARTERS? SUDDEN MOVEMENTS?
TRANSPORTATION
Will you need assistance with transportation to and from scheduled events
DOES CHILD REQUIRE SPECIAL ACCOMODATIONS TO TRANSPORT? IF SO PLEASE EXPLAIN
HISTORY OF CHILDS MEDICAL SITUATION
Briefly explain child diagnosis from Medical Providers
COMMENTS/ A BRIEF STORY ABOUT YOUR CHILD
SIGNATURES
BY Virtual signing below you authorize a 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.
Signature of applicant
Date
Signature of spouse