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If you have a history of any of the following conditions, please tick those that apply:
_____________ heart murmur
_____________ hypertension
_____________ recent infection
_____________ bone fracture in the past six (6) months
_____________ concussion or severe head injury in the past six (6) months (attach doctor's clearance certificate)
_____________ seizures
_____________ eye injury
_____________ severe bone bruises requiring padding
_____________ kidney injury
_____________ allergy to medication (list all)
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Signature of Contestant: __________________________________
Signature of Parent/Guardian: _____________________ (if under 21)
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