Request Form

Participation Request Form
Participant’s Name

First NameLast Name
Birth Date

MonthDayYear
Grade
MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information

(if under 18 years of age)
Name

First NameLast Name
Home Number
Format: (000) 000-0000.
Cell Number
Format: (000) 000-0000.
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.
Does the participant have any allergies, chronic illness, mental, or medical conditions? If yes, please describe.
(Optional) Does the participant have any particular interests or skills?
Code of ConductDress CodeHealth, Safety, and SecurityTransportation ProcedurePhoto and Media Release
Opt-Out
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities scheduled for the Synergy Saturdays weekly program. I also understand that all participation is done voluntarily and is not a mandatory weekly requirement.

I hereby acknowledge that acceptance into the Synergy Saturdays program is not guaranteed upon submission of this request form. The determination will be communicated within 7 days of this form's submission.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date

MonthDayYear
Date
Signature

Powered by Jotform SignClear
Should be Empty:

Participation Request Form