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Youth Outing Student Registration Form
Youth Information
First Name
*
Last Name
*
Address
*
Child Age
*
Date of Birth
*
+
Childs Phone Number
*
Medical Restrictions/Allergies
*
*Additional Child
First Name
Last Name
Address
Medical Restrictions/Allergies
Child Age
Date of Birth
+
Childs Phone Number
PARENT/GUARDIAN INFORMATION & EMERGENCY CONTACT
Parent/Emergency Contact Name
*
Parent/Emergency Contact Phone Number
*
Parent Email Address
*
Please list any specific medical requirements and/or a list of medications:
Upload Insurance Card Information
*
$50.00 per person Non-Refundable Registration (Type the Amount)
*