Adobe FormsCentral

Parent/Guardian Information:

First Name*

Last Name*

Email*

Mobile Phone*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Participant:

Participant First Name*

Participant Last Name*

Date of Birth*

Date of Diagnosis*

Date of Last Treatment*

Type of Cancer*

Are there existing physical conditions/limitations that we should be aware of*

YesNo

Please Describe*

Additional Comments

Are there siblings that would like to participate in the activities?*

YesNo

If yes, please list the names and date of birth for each sibling

Please read the event waiver. It includes releases of liability and waiver of legal rights, and deprives you of the ability to sue certain parties.

Click to review the Wipeout Cancer Event Waiver.

By entering my name below, I assert that I have reviewed and agree to the waiver.

Electronic Signature:*

Emergency Contact:

Emergency Contact First Name*

Emergency Contact Last Name*

Emergency Mobile Phone*

Relationship*

Comments: (enter any notes below)

How did you hear about us?*

If hospital, please list hospital name*

If other, please let us know how*

If flyer, please let us know where you saw it or received it*