New Customer Registration Form

Participant Registration Form
Participant Details:
Full Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
E-mail*
example@example.com
Ethnicity
Gender?*
Disability or additional support needs
Emergency Contact
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Anything we should know about you to support you in participating in our activities?
Suggestions if any for further improvements or ideas for the clubs
I give permission for the use of photos or other social media featuring me (or the person whom i’m completing this form)

YesNo
I give permission to receive emails from Facesuk cic or The Lighthouse sports and social hub

YesNo
Should be Empty:

Participant Registration Form