WAITLIST FOR SOUL BOWLERS REGISTRATION

WAITLIST FOR SOUL BOWLERS REGISTRATION
Saturday, July 9, 2022 – August 6, 2022

AMF Western Branch Lanes

3101 Lynnhurst Boulevard

Chesapeake, VA 23321

11:30 a.m. to 1:30 p.m.
Parent/Guardian Information:
Name:

First Name Last Name
Email:
example@example.com
Cell Phone:
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
PLEASE HELP US CONTINUE TO OBTAIN FUNDING BY ANSWERING THE FOLLOWING QUESTIONS. SOME GRANTS REQUIRE DEMOGRAPHIC INFORMATION. THIS IS OPTIONAL AND YOU MAY PUT “N/A”. ALL INFORMATION IS KEPT CONFIDENTIAL AND ONLY STATISTICAL DATA IS SUBMITTED:
What is your Race/Ethnicity?
Participant Information:
Name:

First Name Last Name
Gender:

Male Female Other
Date:

Month Day Year
Date
Primary Contact:
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email:
example@example.com
Primary Diagnosis:
Any Secondary Diagnosis:
Has Participant bowled before:

Yes No
Any behavioral concerns we should be aware of?

Wandering Running Hitting Biting Other
Any physical concerns?
Does participant have any allergies/intolerance to food or medication?

Yes No
Please explain:
Is participant verbal?

Yes No
Explain how communication is processed?
Can participant follow 1 step directions?

Yes No
Emergency Contact Name:

First Name Last Name
Emergency Contact Phone:
Emergency Contact relation to participant?
What size T-Shirt would you like?

Small (S) Medium (M) Large (L) Xtra Large (XL)
LIABILITY WAIVER: I am aware that participation in the Soul Bowlers has some inherent risks and injury can occur. On rare occasions these injuries can be serious. In consideration of my child being allowed to participate in the five-week program. I, the parent/guardian, assume the risk of all injury and agree not to sue Complete The Puzzle, the directors, coaches, assistant coaches, agents, or volunteers for any and all injuries caused by or resulting from participating in the five-week Soul Bowlers Program. By signing this waiver, I also authorize the use of the pictures of the above-named participant to be posted on Complete The Puzzle’s website or advertising media published by the organization.

AGREE
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WAITLIST FOR SOUL BOWLERS REGISTRATION

Parent/Guardian Information:

Participant Information: