Skateboarding Competition Participant Insurance Form
Participant Information
Full Name
Date of Birth
Address
City
State/Province
ZIP/Postal Code
Phone Number
Email Address
Emergency Contact
Contact Name
Relationship
Contact Phone
Medical Insurance Information
Insurance Provider
Policy Number
Medical Conditions / Allergies
Parent/Guardian (if under 18)
Parent/Guardian Name
Parent/Guardian Phone
I acknowledge that I have read and understood the terms and conditions of the insurance coverage for this event.
Participant Signature
Date
Parent/Guardian Signature
Date