| Rider Name | Dawson Masche |
|---|
| Current Age of Rider | 15 |
|---|
| Age of Rider as of December 31, 2024 | 15 |
|---|
| Cycling Discipline (check one or more) | |
|---|
| Teams | Front Rangers + Highlanders ($460.00) |
|---|
| Team Level | White Team - Goals / Commitments |
|---|
| Which high school will you attend in Fall 2024? | Colorado Springs Christian School |
|---|
| Medical Insurance Carrier | Cigna |
|---|
| Policy # | 3344445 |
|---|
| Parent Name (Primary Contact) | David Masche |
|---|
| Parent Cell Phone # | (505) 366-7613 |
|---|
| Parent Work Phone # | (505) 366-7613 |
|---|
| Parent Email Address | Email hidden; Javascript is required. |
|---|
| 2nd Parent Name | Crystal Masche |
|---|
| 2nd Parent Cell Phone # | (505) 313-9950 |
|---|
| 2nd Parent Email Address | Email hidden; Javascript is required. |
|---|
| Emergency Contact Info | |
|---|
| Emergency Contact Name | Daven Masche |
|---|
| Emergency Contact Phone # | (505) 415-2896 |
|---|
| 1. Has a doctor ever limited your physical activity due to a heart, lung or other condition? | No |
|---|
| 2. Do you have pains in your chest while performing physical activity? or at other times? | No |
|---|
| 3. Do you ever feel faint or have spells of severe dizziness or unconsciousness? | No |
|---|
| 4. Has a doctor ever said your blood pressure was too high? | No |
|---|
| 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 |
|---|
| 6. Are you NOT accustomed to vigorous exercise? | No |
|---|
| 7. Do you suffer from any problems of the lower back, i.e., chronic pain, or numbness? | No |
|---|
| 8. Do you have a disability or other physical limitation that would inhibit participation in a vigorous exercise or certain physical activities? | No |
|---|
| 9. Are you currently taking any medications (prescription or other)? If YES, please specify. | No |
|---|
| 10. Do you currently have a chronic illness or a communicable disease? | No |
|---|
| 11. Do you have any allergies (medicine, bees or other stinging insects)? | No |
|---|
| 12. Do you, or have you had seizures? | No |
|---|
| 13. Have you ever had a head injury? Been knocked out? Or knocked unconscious? | No |
|---|
| 14. Are you missing or overdue on any standard shots (like tetanus, immunizations, etc.)? | No |
|---|
| 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 |
|---|
