Children's Enrollment and Liability Form
Please complete all sections to enroll your child and acknowledge the liability waiver for participation.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Parent/Guardian Full Name
*
First Name
Last Name
Relationship to Child
*
Please Select
Mother
Father
Legal Guardian
Other
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
*
example@example.com
Emergency Contact Name (other than parent/guardian)
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Does your child have any allergies or medical conditions? Please specify.
List any medications your child is currently taking.
Permission for Emergency Medical Treatment
*
Yes, I authorize emergency medical treatment for my child if necessary.
No, I do NOT authorize emergency medical treatment for my child.
Parent/Guardian Signature
*
Submit Enrollment
Submit Enrollment
Should be Empty: