Kicking Bear Youth Camp Registration Form
Participants Details
Child’s Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Name
Gender
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
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Parent Details for Correspondance
Parent/Guardian Name
*
First Name
Last Name
Parent Mobile Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent email
example@example.com
Emergency Contact 1
Emergency Contact Name
*
First Name
Last Name
Home Phone
*
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Participant
Emergency Contact 2
Emergency Contact Name
First Name
Last Name
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Participant
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Does the participant have any dietry requirements
Yes
No
Please specify
Is there any information about the participant that you should disclose in order to protect their, or others, health, safety, comfort, or wellbeing?
Yes
No
If Yes, please specify
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Kicking Bear Liability Waiver
Signature
*
Submit Form
Submit Form
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