BREAKAWAY Registration

BREAKAWAY REGISTRATION PAGE
Participant Name*

First NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Participant Phone Number*
Participant Email*
example@example.com
Birth Date*

MonthDayYear
Date
Age*
Gender*

MaleFemale
Campus Life Club/School*

Abington HeightsLakelandLackawanna TrailValley ViewPen ArgylBlue RidgeCity LifeCrestwoodDunmoreElk LakeMontroseMtn. ViewNorth PoconoPoconoScrantonSusquehannaWallenpaupackWestern WayneWest ScrantonOther
Grade*
Primary Emergency Contact Info
Primary Emergency Contact Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Secondary Emergency Contact
Secondary Emergency Contact Name*

First NameLast Name
Phone Number*
Medical

In case of emergency
Name of Physician*

First NameLast Name
Physician phone Number*
Physician Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I have had a physical within the last 24 months
Medical Insurance Company*
Policy No.*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Allergies (check all those that apply and specific nature of allergic reaction):*

NoneAnimalsEnvironmentalMedicationFoodInsectsLatexOther
Please specify the nature of allergic reaction*
If none, type N/A
PARENT/GUARDIAN CONTACT INFORMATION
Parent/Guardian Name*
Parent/Guardian Phone Number*
Parent/Guardian Email*
Student's Signature*

Clear
Parent/Guardian Signature*

Clear
Calculation
I want to pay nowI want to pay later

Consent and Release of Liability
I represent that I am the participant named below (if 18 or over) or the legal parent/guardian of the child named below, who is under 18 years of age. In consideration for allowing my child to participate in this activity and ongoing YFC activities, I hereby consent to the foregoing on behalf of my child and agree that this release shall be binding upon me, my child, our heirs, legal representatives and assigns.
Participant Name

First NameLast Name
Participant Signature

Clear
Date

MonthDayYear
Date
Parent/Legal Guardian Signature (if participant is under 18)

Clear
Date

MonthDayYear
Date
Parent/Legal Guardian Printed Name:

First NameLast Name
Parent/Legal Phone*
Please verify that you are human*
Should be Empty:

BREAKAWAY REGISTRATION PAGE

Primary Emergency Contact Info

Secondary Emergency Contact

Medical

PARENT/GUARDIAN CONTACT INFORMATION

Credit Card

Consent and Release of Liability