ࡱ> JLIq` N1bjbjqPqP 4<:: bbbb    dr  q |$?h!Q1@qbbCbR" a Y0g"<g"g"}O}}}}}}$  bbbbbb  The Austin Foundation Registration Form PLEASE PRINT LEGIBLY. THANK YOU Participant Name:  FORMTEXT       Date:  FORMTEXT       Age:  FORMTEXT       Mailing Address:  FORMTEXT       City/State/Zip:  FORMTEXT       Email Address:  FORMTEXT       Primary Phone:  FORMTEXT       Other Phone:  FORMTEXT       Please indicate C-Cell FORMCHECKBOX  H  Home FORMCHECKBOX  W-Work FORMCHECKBOX  P-Pager FORMCHECKBOX  Current School:  FORMTEXT       Grade: FORMTEXT       Activities/sports you currently participate in:  FORMTEXT       What program(s) is participant applying for? FORMTEXT       Referral From: Odessa Brown Children s Clinic FORMCHECKBOX  Harborview Children & Teen Clinic FORMCHECKBOX Columbia Health Center FORMCHECKBOX  Other FORMTEXT       Liability Waiver: Participant understands that there is risk involved in physical activities and shall not hold the Austin Foundation or its site partners/facilities liable for any injuries or chronic conditions that might develop as a result of utilization of the facilities or services. Participants waive any claim that may arise in connection with the Austin Foundation or its partners services and/or facilities. Participant further agrees that the Austin Foundation and its partners/facilities shall not be responsible for any property which might be lost or stolen. I also understand that there is no charge for the program(s). I agree to follow the rules of the programs and to use proper etiquette and safety at all times. I understand that it is important for me to be punctual, and be ready to participate by the start time. * Parent or guardian must sign form if participant is under 18 prior to youth start date. Parent or Guardian Signature:  FORMTEXT  6XZ\     $ ȼ܏zjX܏zHXjth< hce>*U#jh< hce>*UmHnHujh< hce>*Uh< hce>*jh< hce>*UhcehEJha5>*CJ\hEJhEJ56>*CJaJhce56>*CJaJhceha>*CJaJhceha>*hcehEJ>*h)hahgjhUmHnHujhvUmHnHu Z\^ 6 2 : < xxgdcexx]^gdce$a$gd$&dP]^a$gdce$]^a$gd ]^gd/L1$ & * , 2 6 8 L N P Z \ ^ n | 󲬦uaOa"jh< hce>*CJU'jh< hce>*CJUmHnHu"j\h< hce>*CJUh< hce>*CJjh< hce>*CJU hceCJ haCJ hEJCJh5>haCJaJ#jh< hce>*UmHnHujh< hce>*Uh< hce>*hahEJhcejh< hce>*U   $ & ( 2 4 D P T V j l n x z | оڪڤЌڪڞzڪڞl]jhce56CJUaJhn gh5>56CJaJ"j,h< hce>*CJU"jh< hce>*CJU haCJ h5>CJ'jh< hce>*CJUmHnHu"jDh< hce>*CJUh< hce>*CJjh< hce>*CJU hceCJ hEJCJhEJhaCJaJ     & ( D F H V X t v x юyke_PFh< hce>*CJjh< hce>*CJU hceCJ hJVCJhn gha56CJaJ)jhcehce56CJUaJhn g56CJaJ)jhcehce56CJUaJ)jhcehce56CJUaJhn gh5>56CJaJjhce56CJUaJ)jhcehce56CJUaJhce56CJaJ  " $ . 0 2 J   ( * , 6 8 : < ſŹ߯ߔ߯|ߎ߯j_h 2ghaCJaJ"jh< hce>*CJU"jZh< hce>*CJU haCJhJVhaCJ"jh< hce>*CJUh< hce>*CJ hceCJ hCJ hJVCJ'jh< hce>*CJUmHnHujh< hce>*CJU"jph< hce>*CJU"< R V Z JLhjlxzñßÍ˅saYQhvCJaJhaCJaJ"jhceCJUaJmHnHu#jhcehceCJUaJhJVCJaJ#j.hcehceCJUaJ#jhcehceCJUaJ#jFhcehceCJUaJhceCJaJjhceCJUaJhJVhJVCJaJhJVhJV5hJVhJV5CJaJhJV5CJaJ< R***+++++++B,,J->.j.. p@ gdxxgdv$a$gdgd &dPgdxx&dPgdceX[I!ӻ{wswf^h< hce>*jh< hce>*Uhcehah5>haCJaJhaha5CJaJh[0T5CJaJh5>5CJaJhah +5CJaJha5CJ\aJhaCJaJh+!CJaJhdCJaJh[0TCJaJhahaCJaJhaha5>*CJ\aJh haCJaJ!!"* * ***&*(***,*@*B*D*N*P*R************+++++&+(+*+T+X+Z+n+p+r+|+~+++㿯˫㿛˗㿇˗wj h< hce>*Ujz h< hce>*Uhvj h< hce>*Uh5>j h< hce>*Uh< hce>*hceha#jh< hce>*UmHnHuUjh< hce>*Uj h< hce>*U.      Date:  FORMTEXT       Please Print Your First & Last Name:  FORMTEXT       Relationship to Participant:  FORMTEXT       Participant Signature:  FORMTEXT       Date:  FORMTEXT       Please complete this form and mail, email, or fax to: Austin Foundation MUST COMPLETE HEALTH HISTORY FORM ANNUALLY 1918 Terry Ave. OR IF ANY CHANGE: Check what session completed: Seattle, WA 98101 Fall FORMCHECKBOX  Winter  FORMCHECKBOX  Spring FORMCHECKBOX  Summer FORMCHECKBOX  Phone: (206) 381-1841 Fax: (206) 381-1840 QUESTIONS: Call Vanisha Duggal at (206) 551-6687 Email:  HYPERLINK "mailto:vanishad@msn.com" vanisha.duggal@gmail.com FAX TO: 206.381.1840 (During business hours, please call first.) For administration purposes only. Date Rec d______ Qtr & Year Applied for ______________ Health History Form Completed__ Yes and Date____ +++++++++++++,$,@,B,j,n,,,,,Ž|rjeZNG@ h5>5\ hk}5\hk35ha5CJ aJ h 2g5>*CJaJ h 2g5htOha5h 56\]hce56\]htOha56\]h5>haCJaJh htO5CJaJh hvCJaJhvCJaJhdCJaJha#jh< hce>*UmHnHujf h< hce>*Uh< hce>*jh< hce>*U,, - ---4-H-J-`-l-v-~------------.....8.:.<.>.t..߽o_X hv5\j: hcehceU\j hcehceU\jP hcehceU\j hcehceU\ hce\jhceU\h h \ hk}5\htOh +5\ h 2g6\hk35h 6\ hce6\ h 2g5\h 2g5>*\h 2gh 2g5>*\ h 5\"...........// /"/l/n/p/|/~////ĶzfRAR!h60J5>*B*CJaJph'hvhv0J5>*B*CJaJph&j hvhk355CJUaJhvhk355CJaJ jhvhk355CJUaJhk355CJaJhk355CJ\aJhd5CJ\aJh0Bha5CJ\aJh 5CJ\aJh5>ha5CJ\aJh ha\ h \h h \ hk355\ hv5\..///204000H1J1L1N1`gdgd ///////002040F1H1J1L1N1h@s#hEJhceCJaJhceCJaJhcehghce6CJaJhce6CJaJhghceCJaJhce5CJaJh 2gh~\5\hk35ha5CJaJhk355CJaJhk35hk355CJaJ21h:p/ =!"#$`% tDText1tDText2tDText3tDText4tDText5tDText6tDText7tDText8tDeCheck4tDeCheck5tDeCheck6tDeCheck7tDText9vDText10vDText11vDText12tDeCheck1tDeCheck2tDeCheck3vDText13vDText14vDText15vDText16vDText17vDText18vDText19tDeCheck8tDeCheck9vDeCheck10vDeCheck11DyK vanishad@msn.comyK 0mailto:vanishad@msn.com@@@ NormalCJ_HaJmH sH tH H@H Heading 1$00@&]0^0CJT@T Heading 2$$00@&]0^0a$ 5CJ\R@R Heading 3$00@&]0^0 5>*CJ\DA@D Default Paragraph FontViV  Table Normal :V 44 la (k(No List @>@@ Title$00]0^0a$CJPJ@P Subtitle$00]0^0a$ 5>*CJ\6U@6 k35 Hyperlink >*B*phB  B < -.NOc]PQRL   DB X w x < = p 0000000000000000000000000000000000000000000I0q000I0I0$ < !+,./N1 < .N1 L1 ams*6<O[ayIU[%5<HN"(8DJq}  $ 0 @ FFFFFFFFG G G G FFFFG$G$G$FFFFFFFG G G G XD89@R8(  H  #  h   S  "` B S  ? L+ttText1Text2Text3Text4Text5Text6Text7Text8Check4Check5Check6Check7Text9Text10Text11Text12Check1Check2Check3Text13Text14Text15Text16Text17Text18Text19Check8Check9Check10Check11_~+PzJ%=9r 1  t=b\6O)K % A jjj ,j \,j ,j+j dj j t`:@ cDEJKxMtOS[0TJVn gg 2g)+!ce~\0B +]& ve_k}Cda6Z@nnT"nnL#   @*UnknownGz Times New Roman5Symbol3& z Arial"qhʪfʪfLkF }~}~24d 2HX(? +2-The Austin Foundation & Gateway Athletic Club Jan ShelbyKasandra VerBrugghenOh+'0, LX x   0The Austin Foundation & Gateway Athletic Club Jan ShelbyY&FRegistrationFormKasandra VerBrugghen4Microsoft Office Word@d@f@Ԍ^@<#a}~՜.+,D՜.+,h$ hp  Austin Foundation  .The Austin Foundation & Gateway Athletic Club Title 8@ _PID_HLINKSAh.Omailto:vanishad@msn.comd   !"#$%&()*+,-./012345678:;<=>?@BCDEFGHKRoot Entry FaMData 1Table'g"WordDocument4<SummaryInformation(9DocumentSummaryInformation8ACompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q