Wednesday Class Form

Intake & Release Form

To ensure the safety and well being of every participant we ask that all legal guardians fill this form out. Please answer dietary restrictions, allergens, and medications to the best of your ability.
1) Participant Information
Participant Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City*
State*
Zip Code*
School (Optional)
2) Parent / Guardian Information
Parent / Guardian Name*

First NameLast Name
Relationship to Participant*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Secondary Emergency Contact
Emergency Contact Name*

First NameLast Name
Relationship to Participant*
Emergency Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
3) Medical Information
Primary Physician Name*
Primary Physician Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Health Insurance Provider (Optional)
Policy Number (Optional)
Known Medical Conditions*
4) Allergies & Food Sensitivities
Food Allergies*
Environmental Allergies*
YesNo
Location of EpiPen*
5) Medications
Medications*
YesNo
YesNo
6) Dietary Restrictions
NoneVegetarianVeganGluten-FreeOtherOther
Additional Notes on Dietary Restrictions
7) Photo, Video & Live Streaming Consent
Permissions Granted*
Parent/Guardian Initials*
8) Technology & Online Conduct Agreement
By participating, I acknowledge that I will behave respectfully, avoid harassment, follow game ratings, and not tamper with equipment.
Parent/Guardian Initials*
9) Liability Waiver & Assumption of Risk
I acknowledge and accept the liability waiver and assume all risks related to participation.
Parent/Guardian Initials*
10) Emergency Medical Authorization
I authorize emergency medical treatment if necessary during participation.
Parent/Guardian Initials*
11) Behavior & Equipment Responsibility
I acknowledge responsibility for behavior and equipment during participation.
Parent/Guardian Initials*
12) Pickup Authorization
Authorized Pickup Persons*
13) Proof of Age Verification
Upload Proof of Age Document*

Cancelof
14) Parent / Guardian Electronic Signature
Parent / Guardian Full Legal Name*

PrefixFirst NameMiddle NameLast NameSuffix
Electronic Signature*

Clear
Date*

MonthDayYear
Date
By electronically signing, I certify that the information provided is accurate and I agree to the liability waiver terms.
Should be Empty:

Intake & Release Form

1) Participant Information

2) Parent / Guardian Information

Secondary Emergency Contact

3) Medical Information

4) Allergies & Food Sensitivities

5) Medications

6) Dietary Restrictions

7) Photo, Video & Live Streaming Consent

8) Technology & Online Conduct Agreement

9) Liability Waiver & Assumption of Risk

10) Emergency Medical Authorization

11) Behavior & Equipment Responsibility

12) Pickup Authorization

13) Proof of Age Verification

14) Parent / Guardian Electronic Signature