Ice Cream Consent Sign Up Form January 19, 2026
Ages 5-10 from 10 am until 12 pm Ages 11-17 from 1 pm until 3 pm
Please input the First and Last Name & Date of Birth for each child you are registering in a separate line.
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Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Emergency Contact Name
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First Name
Last Name
Relationship
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Phone Number
*
Please enter a valid phone number.
Preferred Medical Facility
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Name of Physician/Pediatrician
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Any Allergies or Medical Conditions?
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Yes
No
Please give details
Do you want to add something about your child?
Please upload a profile picture of the child
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I, undersigned, agree with the following statements:
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I am the parent/guardian of the child indicated above.
If emergency medical care is needed and I am unavailable, I authorize the Women's Center staff, interns, or consultants to seek medical treatment for my child.
I am giving my permission to take my child's pictures and for them to be shared on social media and in WCGL materials.
Date
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Month
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Day
Year
Date
Signature
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My Products
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Product Name
$
30.00
Quantity
1
2
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4
5
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10
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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