Participant Registration Form

Participant Registration Form

Please fill out the form below thoroughly.
Team Name
Enter Team Name
Team Captain
Enter Team Captain's Name
- Participant Name*
  
  First NameLast Name
- Gender*
- Age*
- Date of Birth
  
  MonthDayYear
- YesNo
- Additional Participants
  
  First NameLast Name
- First NameLast Name
- First NameLast Name
- First NameLast Name
- Emergency Contact
  
  First NameLast Name
- Mobile Phone
  Format: (000) 000-0000.
- Home Phone
  Format: (000) 000-0000.
- E-mail
  example@example.com
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Steppin’ for Abilities Statement
  
  I am signing this form for myself (or for the participant named if he or she is a minor). I understand and agree to absolve the E. John Gavras Center, and all sponsors, be they individuals or organizations, singly or collectively, of all blame for injury, misadventure, harm, loss or inconvenience suffered in any of the activities associated with this event.
  
  **Pictures taken at the event may be posted on our social media sites.**
- By signing and submitting this registraiton form, you understand and agree to all policies.
- Parent/Guardian Signature*
  
  First NameLast Name
- Today's Date*
  
  MonthDayYear
  Date
- YesNo
- What size shirt?
- Do you need additional shirts? If yes, please add sizes below:
- Use the form below to collect pledges toward your $25 shirt fee.
- Should be Empty: