| Rider Name | Landon Jacobs |
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| Current Age of Rider | 14 |
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| Age of Rider as of December 31, 2024 | 15 |
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| Cycling Discipline (check one or more) | |
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| Teams | Highlanders Only ($320.00) |
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| Team Level | White Team - Goals / Commitments |
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| Which high school will you attend in Fall 2024? | Liberty High School |
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| USAC Cycling License # | 661613 |
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| Medical Insurance Carrier | United Healthcare |
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| Parent Name (Primary Contact) | Lindsey Jacobs |
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| Parent Cell Phone # | (314) 814-0259 |
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| Parent Email Address | Email hidden; Javascript is required. |
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| 2nd Parent Name | Joe Jacobs |
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| 2nd Parent Cell Phone # | (314) 607-4388 |
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| Emergency Contact Info | |
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| Emergency Contact Name | Nan Hargett |
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| Emergency Contact Phone # | (479) 650-5381 |
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| 1. Has a doctor ever limited your physical activity due to a heart, lung or other condition? | No |
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| 2. Do you have pains in your chest while performing physical activity? or at other times? | No |
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| 3. Do you ever feel faint or have spells of severe dizziness or unconsciousness? | No |
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| 4. Has a doctor ever said your blood pressure was too high? | No |
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| 5. Has your doctor ever told you that you have a bone or joint problem(s), such as arthritis that is aggravated by exercise, or might be made worse with exercise? | No |
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| 6. Are you NOT accustomed to vigorous exercise? | No |
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| 7. Do you suffer from any problems of the lower back, i.e., chronic pain, or numbness? | No |
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| 8. Do you have a disability or other physical limitation that would inhibit participation in a vigorous exercise or certain physical activities? | No |
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| 9. Are you currently taking any medications (prescription or other)? If YES, please specify. | No |
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| 10. Do you currently have a chronic illness or a communicable disease? | No |
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| 11. Do you have any allergies (medicine, bees or other stinging insects)? | No |
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| 12. Do you, or have you had seizures? | No |
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| 13. Have you ever had a head injury? Been knocked out? Or knocked unconscious? | Yes |
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| 14. Are you missing or overdue on any standard shots (like tetanus, immunizations, etc.)? | No |
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| 15. Is there any other reason, condition, or other health information the coaching staff should be aware of, or that would limit your participation in a vigorous exercise program? | No |
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