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Rider NameArtem Chizhov
Current Age of Rider14
Age of Rider as of December 31, 202414
Cycling Discipline (check one or more)
  • Mountain
TeamsFront Rangers Only ($220.00)
Medical Insurance CarrierKaiser Permanente
Policy #439182524
Parent Name (Primary Contact)Vladimir Chizhov
Parent Cell Phone #(650) 484-8886
Parent Email AddressEmail hidden; Javascript is required.
2nd Parent NameMaria Chizhova
2nd Parent Cell Phone #(650) 309-6361
2nd Parent Email AddressEmail hidden; Javascript is required.
Emergency Contact Info
Emergency Contact NameStephen Stock
Emergency Contact Phone #(910) 600-2890
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