WP - Student Intake

Student Intake

Emergency information and Waiver
Student Name

First NameLast Name
Phone*
Student's direct phone number for communication throughout the semester.
Email*
Student's direct email for communication throughout the semester.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
Are you (the student) over 18 years old?*

YesNo

Emergency Contacts
Emergency Contact #1*

First NameLast Name
Contact #1 Mobile Phone*
Please enter a valid phone number.
Contact #1 Home Phone
Please enter a valid phone number.
Contact #1 Relationship*
Emergency Contact #2*

First NameLast Name
Contact #2 Mobile Phone*
Please enter a valid phone number.
Contact #2 Home Phone
Please enter a valid phone number.
Contact #2 Relationship*

Medical Information
Do you have any known allergies?*

YesNo
Please share any allergies we should be aware of.*
Do you have any dietary restrictions?*

YesNo
Please share any restrictions we should be aware of.*
Any other medical information we should know in case of emergency?*

YesNo
Please explain.*
Insurance Company
Policy Number
Preferred Hospital
Do you have any physical conditions that would affect your ability to perform any construction activities?*

YesNo
Please explain your limitations.*
I certify that all the information provided is correct.

Waiver of Liability
Legal Guardian Name*

First NameLast Name
Legal Guardian Signature*

Clear
Student Name*

First NameLast Name
Student Signature*

Clear
Today's Date*

MonthDayYear
Should be Empty: