Rider Name | Carsten Varcie |
---|
Current Age of Rider | 14 |
---|
Age of Rider as of December 31, 2024 | 14 |
---|
Cycling Discipline (check one or more) | |
---|
Teams | Front Rangers Only ($220.00) |
---|
Medical Insurance Carrier | United Healthcare |
---|
Policy # | 985813176 |
---|
Parent Name (Primary Contact) | Jeffrey Varcie |
---|
Parent Cell Phone # | (951) 403-3029 |
---|
Parent Email Address | Email hidden; Javascript is required. |
---|
2nd Parent Name | Ashley Varcie |
---|
2nd Parent Cell Phone # | (951) 403-2266 |
---|
2nd Parent Email Address | Email hidden; Javascript is required. |
---|
Emergency Contact Info | |
---|
Emergency Contact Name | Dora Poarch |
---|
Emergency Contact Phone # | (307) 575-8737 |
---|
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 |
---|