Cabot Moonlighters Disc Golf League | Faith-Based Community in Central Arkansas

1. Applicant Information

Child's Full Name

Date of Birth

Age

Gender

School

Grade Level

Emergency Contact (Name & Phone Number)

2. Parent/Guardian Contact Information

Parent/Guardian Full Name

Relationship to Child

Phone Number

Email Address

Street Address

3. Medical Information

This information is essential for the safety of your child. All information will be kept confidential.

Does your child have any known allergies (food, medication, insect stings, etc.)? Yes No

Does your child have any pre-existing medical conditions (e.g., asthma, diabetes,epilepsy)? Yes No

Please list any current medications your child is taking:

Name of Primary Healthcare Provider:

Phone Number of Healthcare Provider:

4. Waiver and Consent

5. Release of Liability and Assumption

6. Signature

Parent/Guardian Name

Date

PDGA is the sanctioning body of our sport. Please visit pdga.com and secure your child's PDGA number. This signifies when they got into the sport and is an essential part of your child's disc golf journey.

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