Heatwave Registration & Medical Form
I am a
*
Student
Leader
Campus Life Club
*
Hanover Area
Westminster Area
Manchester Valley
Shiloh/NC Middle
EHMMS/Hanover Middle
Bermudian Springs Middle
New Oxford Middle
Northwest Middle
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Participant Email
*
example@example.com
Participant Phone Number
*
Please enter a valid phone number.
Participant Birthday
-
Month
-
Day
Year
Date
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Email
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.
Participant Health Insurance Group/Provider
Policy Number
Medication
Allergies
Emergency Contact
*
First Name
Last Name
Emergency Contact Mobile Phone Number
*
Please enter a valid phone number.
Alternate Emergency Contact
First Name
Last Name
Alternate Emergency Contact Phone Number
Please enter a valid phone number.
Participant T-shirt Size
*
Small
Medium
Large
XL
XXL
XXXL
Participant and Parent/Guardian have read the Student Guidelines and Expectations and agree to abide by all expectations.
*
Yes
No
I understand that this registration is not completed until a $50 nonrefundable deposit is made.
Parent/Guardian Signature
Submit
Should be Empty: