Pop Douglas Clinic Participant Information
If registering multiple, please fill out a registration form for each participant.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
We separate groups based on age.
Emergency Contact
Name
*
First Name
Last Name
Relationship to Participant
*
Email
*
example@example.com
Phone Number (Best to Use During Clinic)
*
-
Area Code
xxx-xxxx
Address
*
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Payment Information
My Products
*
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Clinic Registration
$
99.00
Online Registration Fee
$
5.00
Total
$
0.00
Credit Card
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*
Submit Registration
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