Full Legal Name
*
First Name
Last Name
Adress
Adress
Street Address Line 2
City
State / Province
Postal / Zip Code
City / State / ZIP
City / State / ZIP
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth :
*
/
Month
/
Day
Year
Date of Birth :
Email
*
Email
Phone
*
Phone
Format: (000) 000-0000.
Initials
*
Emergency Contact - Name
*
Emergency Contact - First Name
Last Name
Emergency Contact - Phone
*
Emergency Contact - Phone
Format: (000) 000-0000.
Media & Image Right
I AGREE to the media release above
I DO NOT AGREE to the media release
Signature
*
Date
*
/
Mois
/
Jour
Année
Date
Testing location
*
REDONDO Beach Store
SKwheel Waiver California
Participant declarations - Please initial each box
*
I am 18 years of age or older and I have valid proof of age available upon request.
Soumettre
Should be Empty: