Participant’s Name
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Date of Birth
MM slash DD slash YYYY
Parent/Guardian Name
First
Last
Home Phone
Cell Phone
Email
Contact Person’s Name
First
Last
Emergency Phone
Family Insurance Carrier
Policy Number
Does your child have any food or other allergies? If yes, please explain.
Authorization
*
Checking this box is equivalent to your signature
THIS CHECK BOX MUST BE CHECKED BY PARENT AND/OR GUARDIAN BEFORE REGISTRATION IS ACCEPTED.