Pride Night Registration Form
Saturday, June 6
Name
*
First Name
Last Name
Age:
*
City/Town:
E-Mail Address
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Format: (000) 000-0000.
Do you give permission for yourself as the participant to appear in any media coverage (i.e. photos for our brochure, social networking, newspapers), approved by the Rec. Dept.?
*
Please Select
Yes
No
Please list any pertinent medical information
Submit
Should be Empty: