The Blue Ridge Athlete at Heart Event is for rising 6th through 12th Grade Athletes who are enrolled in a Public, Private or Home School
 *Please take the time to read through the questions, and answer to the best of your knowledge*
* = Required Information
*Have you ever participated in Athlete at Heart before?   If Yes, what years?
This form is for the 2018-19 School Year
Please pick your school and event time:
*There will be a registered Dietitian on site if your child would like to receive a consultation*
Personal Emergency Contact Information
*School Attending:   *Grade Entering:  
*First Name:   Middle Initial: *Last Name:  
*Street Address:   Apt/Unit: *City:  
*State:   *Zip:   *Phone#:  
*DOB:   Race: *Age:  
*Gender:   Email:    
    Verify Email:      

Parent/Guardian Information
* Parent(s)/Legal Guardian(s) Last Name:   * Who Has Custody:  
* Fathers Name:   * Alternate Phone (Work/Cell):  
* Mothers Name:   * Alternate Phone (Work/Cell):  
Family Physician/Pediatrician: Physician Phone:
* Preferred Hospital:   *Permission To Transport To Hospital:  
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