WHY TRY Student Registration Form Parent/Guardian First Name *Parent/Guardian Middle NameParent/Guardian Last Name *Parent Email Address *OccupationHome Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Mobile/Home Phone *Parent Work PhoneStudent First Name *Student Middle NameStudent Last Name *Gender *MaleFemaleDate of Birth *Age *Name of School/Organization:School/Organization PhoneSchool/Organization Street AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeHow did you hear about us?Medical History Intake FormName of General Practitioner or DoctorStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodePlease indicate if you have had any of the following concerns in the past year, or of significance in the past couple of months.Nose and SinusSinus infectionsSinus painHay feverRunny noseRespiratoryShortness of BreathWheezingCoughAsthmaNeurologicalFaintingDizzinessNumbness/TinglingSeizuresHeadaches or migrainesMemory LossProblems with sleepMental/Emotional HealthDepressionAnxietyInsomniaMood SwingsAnger/FrustrationIrritabilityPlease list anything else or elaborate on the above if you would like.Health Assessment and Medical InformationAre you taking any medications? Include any prescription drugs, over-the-counter medication, birth control pill etc..YesNoAre you taking any supplements, minerals/vitamins, herbs or other natural healthcare products?YesNoAny known allergies?Dietary and Lifestyle HabitsHow often do you exercise?Times per weekWhat kind of exercise?Do you have any known (or suspected) food allergies or intolerances?YesNoPlease list:Do you have any dietary restrictions? (e.g., religious, vegan/vegetarian)YesNoPlease specifyPlease indicate how many cups of the following you drink per day, based on a standard mug size.WaterCoffeeTeaHerbal TeaJuiceColaDo you consume alcohol?YesNoDo you smoke tobacco?YesNoIn the pastAre you regularly exposed to second hand smoke?YesNoI don't knowDo you use recreational drugs?YesNoPlease list which kinds, and how often.Sleep, Energy and Stress LevelsPlease rate your energy level on a scale from 1-10123456789101 = Lowest - 10 = HighestOn average, how many hours of sleep do you get?Select oneLess than 55-78-99-11Do you have difficulty falling asleep?YesNoSometimesPlease rate your stress level on a scale from 1-10123456789101 = Lowest - 10 = HighestWhat are some stressors in your life?Please quickly rate your level of satisfaction with the following areas of your life. (1 = not satisfied, 5 = very satisfied)Health1 2345 1 = Not satisfied - 10 = Very SatisfiedDiet1 2345 1 = Not satisfied - 10 = Very SatisfiedFitness Level/Physical Activity1 2345 1 = Not satisfied - 10 = Very SatisfiedFamily and Friends123451 = Not satisfied - 10 = Very SatisfiedLiving/Home Environment12345 1 = Not satisfied - 10 = Very SatisfiedIs there anything else you would like to add that you feel is important and has not been covered?Thanks for taking the time to complete this intake form.Parental Consent *I, do hereby give my consent to the participation of my youth in all of the scheduled youth activities of the Why Try Youth Program and any other supervised activities associated with the youth program and its group. Further, I certify that my youth is physically fit to participate in any of the mild to moderate recreational activities associated with the Why Try Youth Program. I also understand that this program will feature content related to youth mental health and discussions on issues that impact youth today. I understand that I can revoke my consent at any time during the program and will notify the program leaders if and when I choose to withdraw my youth from the program. I also understand that I will be notified in the case of a medical emergency. In the event that I cannot be reached, I authorized the calling of 911 for emergency dispatch, a doctor, or other emergency medical services in the event that my youth becomes injured or ill. I understand that the Why Try Youth Program, leaders, and its facilitators will not be responsible for any medical expenses that are incurred solely on the basis of this authorization. I further agree to notify the program leaders and facilitators of any health changes that would restrict my youth from participating in any of the program activities. I also understand that the program leader and facilitators have the right to restrict my youth from participation in any of the program activities if and when they feel the activity is not within the physical capabilities of my youth.Submit Registration