Attendee Registration Form
Fill out the form carefully for registration. Any information provided here is confidental and for use of this event only.
Attendee Name
First Name
Middle Name
Last Name
Gender
Please Select
Male
Female
N/A
Birth Date (month, day, year)
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Guardian
Please select a day
1
2
3
4
5
6
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31
required if
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
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1928
1927
1926
1925
1924
1923
1922
1921
1920
under age 18
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail (for ticket confirmation)
example@example.com
Home or Cell Number
Do you authorize the use of any photos taken during the event?
Yes
No
Guardianship & Emergency Contact Information
Are you your own guardian?
Yes
No
If no, list name of Emergency Contact (Emergency contact MUST be available that night)
Emergency Contact Phone
Emergency Contact Email Address
Emergency Contact Relationship to Attendee
Health Information
Will any medications be required to take during the event?
Yes
No
If yes, what medications?
Any health concerns we should be aware of? (ie: Seizures, vision problems, hearing loss, high blood pressure, mobility, etc.) SPECIAL NOTE: If diabetic a chaperone MUST attend if the attendee CANNOT manage their needs on their own.
Do you have any dietary restrictions or food allergies that we need to know about?
Yes
No
If yes, please list the restrictions or allergies (ie: gluten-free, peanuts, etc.)
Bathroom Assistance Needed? If yes, chaperone must attend
Yes
No
Any other concerns/issues we should be aware of?
Name of person filling out form?
I agree that the information provided is true and accurate and I accept any responsibility. This also is an acknowledgement of my signature.
Yes
No
Other
Name of person you are chaperoning
Only needs to be filled in for chaperones registering
Submit
Should be Empty: