Participant Information
Youth Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Age
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School
Grade Level
Insurance Provider Name
Medical Insurance Information
Provide the medical insurance number.
What allergies does the child have?
Please specify any known allergies.
Does the child have any medical conditions that we should be aware of (e.g., any medications the participant is currently taking)?
Tell us about yourself (e.g., skills, likes, dislikes, or hobbies that make you unique).
Parent/Guardian Information
Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Information
Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I acknowledge and agree to the following statements
I agree to follow the guidelines, rules, and policies of the organization.
I agree to chaperone and provide transportation as needed.
I allow my child to be photographed or be part of the video that will be used for marketing, promotiion, and advertisements.
Repeated offenses of my child may result in suspension or expulsion.
Parent/Guardian registered in this form has legal custody over the child.
I allow my child to ride any vehicle that is related to the group's activities provided that there's an adult on board.
For medical emergencies, I allow the medical team of this organization to take care of my child.
I release this organization from any and all liability from accident or injury to my child during the organizations related events.
Type a question
No, I do not permit PHN to take photos or videos of my child.
Parent/Guardian Signature
Youth Signature
Date Signed
-
Month
-
Day
Year
Date
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Submit
Should be Empty: