Obstacle Course Registration Form
Enhance Your Child’s Gross Motor Skills
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Female
Male
Is the participant have any chronic medical illnesses such as diabetes, asthma (exercise asthma), kidney problems, etc.?
Yes
No
Please explain
Is the participant have any allergies?
Yes
No
Please explain
Please upload medical health document(s) (if applicable)
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Parent/Guardian & Emergency Contact
I, the parent of the participant, agree with the following statements:
I grant MEYES permission to take and use video, photographs, and/or digital images of me and my child/children in news releases, promotional projects, and/or educational materials.
I give permission for my child to participate in Obstacle Course Program at Maine Youth Empowerment Services (MEYES)
Assume all risk of possible damage or injury involved through participation in the above-noted activities. I release this organization from any and all liability from accident or injury to the child during the organization related events.
I will respect and obey all laws and the athlete's Code of Conduct.
Date
-
Month
-
Day
Year
Date
Signature (Athlete or Parent/guardian)
Submit
Should be Empty: