The York Heart Of A Champion Day is for rising 9th through 12th Grade Athletes who are enrolled in a Public School
 *Please take the time, read through the questions, and answer to the best of your knowledge*
* = Required Information
*Have you ever participated in Heart of a Champion Day before?   If Yes, what years?
*Have you ever participated in organized football wearing a helmet, such as Pop Warner?   At what age did you begin?
   
*There will be a registered Dietitian on site if your child would like to receive a consultation*
Personal Emergency Contact Information
Student ID: *School Attending:   *Grade Entering:  
*First Name:   Middle Initial: *Last Name:  
*Street Address:   Apt/Unit: *City:  
*State:   *Zip:   *Phone#:  
*DOB:   Race: *Age:  
*Gender:   Email:    

Parent/Guardian Information
* Parent(s)/ Legal Guardian(s) Residing With:   * Who Has Custody:  
* Fathers Name:   * Alternate Phone (Work/Cell):  
* Mothers Name:     * Alternate Phone (Work/Cell):  
Family Physician/Pediatrician: Physician Phone:
* Preferred Hospital:   *Permission To Transport To Hospital:  
 Page 1 of  8