Registration Form
General Information
Which service are you registering for?
*
Please Select
Group - Foxfire Birthday Bash
Individual - The Element of Fire
Individual - The Element of Wood
Individual - Pilot Program
Who are you registering for?
*
Myself
My child
Another adult
Your Name
*
First Name
Last Name
Participant Name
*
First Name
Last Name
Nickname
Preferred Pronouns
she/her
he/him
they/them
Birthday
*
-
Month
-
Day
Year
Date
Primary Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Email
*
example@example.com
Primary Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about us? (Select all that apply.)
*
Friend
Family
School
Social Media
Internet Search
Community Event
Other
Who recommended?
Which school?
Which community event?
Medical Information
All medical information will remain confidential. We ask for this information to know how best to support you at our programs and in case of an emergency.
Participant Gender
*
Helpful to know in case of a medical emergency. All are welcome at our programs.
Any Allergies? (Food, medicine, plants, insects, etc.)
*
Yes
No
Participant Allergies
If so, please list and describe severity...
Any Medications? (Penicillin, aspirin, etc.)
*
Yes
No
Participant Current Medications
Please list along with possible side effects that could occur at program.
Any other medical information or physical support needs we should be aware of?
Physician Name
*
Physician Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Emergency Contact Relationship
*
Waivers and Agreements
Please read the following waivers and agreements carefully. They include release of liability and waiver of legal rights, and deprive you of the ability to sue certain parties. By agreeing electronically, you acknowledge that you have both read and understood all text presented to you as part of the registration process.
Signature Preference
*
Write your signature
Type your signature
Electronic Signature
*
By signing my name above, I acknowledge that I have read and agree to all the waivers and agreements that I have selected above.
Electronic Signature
*
By entering my name above, I assert that I have reviewed and agree to all the waivers and agreements I selected above.
Submit
Submit
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