Rider Name | Jack Grussendorf |
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Current Age of Rider | 15 |
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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 | Front Rangers Only ($60.00) |
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Medical Insurance Carrier | Tricare |
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Policy # | 1258104974 |
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Parent Name (Primary Contact) | Lisa Grussendorf |
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Parent Cell Phone # | (410) 206-9726 |
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Parent Work Phone # | (410) 206-9726 |
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Parent Email Address | Email hidden; Javascript is required. |
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2nd Parent Name | Chris Grussendorf |
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2nd Parent Cell Phone # | (405) 403-2360 |
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2nd Parent Work Phone # | (405) 403-2360 |
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2nd Parent Email Address | Email hidden; Javascript is required. |
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Emergency Contact Info | |
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Emergency Contact Name | Joshua Grussendorf |
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Emergency Contact Phone # | (719) 318-8895 |
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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? | No |
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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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