Number of Youth being registered
Please Select
1
2
3
4
5
Youth Information
Youth Name 1
First Name
Last Name
Age and Grade 1
Age
Grade Level
Youth Name 2
First Name
Last Name
Age and Grade 2
Age
Grade Level
Youth Name 3
First Name
Last Name
Age and Grade 3
Age
Grade Level
Youth Name 4
First Name
Last Name
Age and Grade 4
Age
Grade Level
Youth Name 5
First Name
Last Name
Age and Grade 5
Age
Grade Level
Do any of the youth have any allergies or dietary restriction?
Do any of the youth have any medical conditions that we should be aware of?
Parent/Guardian Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is there any Custody or Pick-up preferences that we should be aware of?
Emergency Contact Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Acknowledgment
I agree to follow the guidelines, rules, and policies of the organization.
I allow my child to be photographed or be part of the video that will be used for our newsletter or among the PAX North Community. Photos and Videos will not be shared publicaly (ie. Social Media, Marketing, Promotion, Advertising etc.) without previous approval and permission by subject and/or legal guardain.
The repeated offense of the youth 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 the child during the organization related events.
Concerns or Notes from Parent/Guardian
Parent/Guardian Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: