Champions Registration Form (2025)

Champions Registration Form (2025)

PARTICIPANTS MUST BE 18 OR OLDER
Participant Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*
Diagnosis*
Seizures*

YesNo
If yes, are seizures controlled by medication?*

YesN/A
Do you have any allergies?*
Parent/ Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I consent to allow the Champions Team to Film/ take Photos freely at events to use for Website, Social Media and Promotional material.*

Yes, I consent
Parent/Guardian E-mail*
example@example.com
Contact Number Number*
Emergency Contact Name*
Emergency Contact Phone Number*
If the board deems it necessary, should any behaviors or medically fragile events arise, an individual may be required to be accompanied by a caregiver.*

I understand and acknowledge the above statement.
Please add any additional information about your participant that would help us better serve them.
I give permission for the Champions participant to participate in the activity organized by Champions. I understand that this activity will involve transportation and I give my consent for the participant to be transported in a vehicle provided by Champions or a contracted transportation service.

I understand that the mode of transportation may include buses, vans, or cars and that the transportation may take place on public roads. I understand that Champions will take all necessary precautions to ensure the safety of my participant during transportation.

In the event of an emergency during transportation, I authorize Champions or a contracted transportation service to seek medical attention for my participant if needed. I understand that I will be notified as soon as possible if such an emergency occurs.
I acknowledge that I have read the above permission slip and agree to all of it's terms and conditions.*

Yes
Should be Empty: