INFORMATION

SHEET

NAME

DOB

ADDRESS

CITY

STATE

ZIP

EMAIL

PHONE#

MALE

FEMALE

If under 18 years old, fill out this section

PARENTS NAME

PARENTS PHONE#

PARENTS EMAIL

DO YOU HAVE ANY GUARD EXPERIENCE?

YES

NO

WHERE HAVE YOU MARCHED?

HOW MANY YEARS AND CHECK EQUIPMENT EXPERIENCE?

FLAG
RIFLE
SABRE

DO YOU HAVE ANY DANCE EXPERIENCE/TRAINING? YES NO

IF YES, HOW MANY YEARS AND LIST EXPERIENCE




















































IF WEAPON, WHAT PIECE OF EQUIPMENT ARE YOU INTERESTED IN AUDITIONING FOR?
RIFLE SABRE BOTH


THE MARK MEDICAL FORM & AUTHORIZATION

NAME:












NAME OF RELATIVE TO BE CONTACTED IN CASE OF EMERGENCY & PHONE #:

PHYSICIAN

PHONE #

HEALTH ISSUES

MEDICATIONS

ALLERGIES

PLEASE CHECK IF YOU HAVE HAD ANY OF THE FOLLOWING IN THE PAST 4 YEARS:

Asthma



Hepatitis

Epilepsy


Bronchitis

Stroke



Heart Attack

Chest Pain


Ulcers Stomach/Intestinal

Fractures/Broken Bones
Fainting/Dizzy Spells

Diabetes


Shortness of Breath

INSURANCE COMPANY




ID #

I hereby give my consent for a qualified physician or surgeon to examine, diagnose, prescribe and perform treatment,
including surgery, that they deem advisable for the welfare of the above listed patient. I hereby give consent for the
transfer of the member to any hospital reasonably accessible. I understand that no one connected with The Mark
Winter Guard or the facility in which we are in assumes liability for any injury incurred by the participant. I agree to pay
all medical costs incurred by the participant including hospital bills, physician fees, and ambulance fees. I understand
that someone in authority will contact the relative listed above at the time they are admitted to the hospital and /or
treated by a physician.

Print Name

Date

(If under 18, must be signed by Parent/Guardian)

Signature