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Braelen's Speed Shop New Client Form
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Email *
ATHLETE'S Name *
First & Last
ATHLETE'S Date Of Birth *
MM
/
DD
/
YYYY
ATHLETE'S Address, City, State, Zip Code *
ATHLETE'S Phone Number *
If available
PARENT/GUARDIAN'S  Relationship To Athlete *
PARENT/GUARDIAN'S Name *
First & Last
PARENT/GUARDIAN'S Date Of Birth *
MM
/
DD
/
YYYY
PARENT/GUARDIAN'S Address, City, State, Zip Code *
PARENT/GUARDIAN'S Phone Number *
Emergency Contact *
Include First And Last Name, And Phone Number
Past Injuries *
Medical Restrictions *
Prescriptions/Medications *
Do you have chest pain brought on by physical activity? *
Have you ever been diagnosed with high/low blood pressure? *
Have you ever been diagnosed with diabetes? *
Have you ever been diagnosed with high cholesterol? *
Have you ever been diagnosed with any other medical condition? *
If you answered YES to "Have you ever been diagnosed with any other medical condition?" please list the medical conditions.
What sports do you participate in or would like to participate in? *
Required
If you answered OTHER to "What sport …" type the sport(s).
What are your athletic goals? *
Why is this important to you? *
What made you choose Braelen's Speed Shop? *
How did you hear about Braelen's Speed Shop? *
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