KC Power & Speed Co. Application Form

KC Power & Speed Co. Application Form

KC Power & Speed Sign-Up Form

First Name *

First

Last Name *

Last

Date of Birth

County

Address: *

City *

State * - Select a State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code *

Email *

Phone *

Gender Male Female N/A

Please share the nature of your disability:

Sports Program Classification

Place of Residence ISL Group Home With Family or Guardian Apartment

If you live in a group home or ISL, please list the organization who provides your services

Name of Day Program, Place of Employment, Workshop or Volunteer Program

Name of person to notify in case of emergency *

Address, City, State and Zip of Emergency Contact *

Phone of Emergency Contact *

Email of Emergency Contact *

Name, Phone and Address of Your Physician *

Medications (List All) *

Allergies *

Blood Type *

Do you have seizures?

Yes

No

Type of seizures, if applicable, and # of seizures in the past 12 months

Date of most recent seizure, if applicable

Other information related to your health that you'd like us to know

If you are human, leave this field blank.