KC Power & Speed Co. Application Form KC Power & Speed Co. Application Form KC Power & Speed Sign-Up Form If you are human, leave this field blank. 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