Class/level: _________________________ Today’s Date: _______________

Start Date: ___________ End Date: __________

Participant’s Information:

Name: __________________________________________________________

Address/City/Zip: _________________________________________________

Phone: __________________________________________________________

Birth Date: ___________ Age: ___________ Gender: M/F

***Parental/Legal Guardian section if under 18***

Name: _____________________ Work/Cell Phone: _____________________

Email Address: ___________________________________________________

Please Check One:

________ Medical Denial: I do not give my consent for any emergency medical treatment or  

                 transfer to any medical facility.

________ Medical Release: In the event of an emergency and if all reasonable attempts to reach

                parents at the above phone numbers in unsuccessful, I hereby give my consent for the

               administration of emergency medical treatment or transfer of participant to closest

             emergency medical facility.

Please list any medical conditions: ___________________________________

Parent/Legal Guardian Signature: ___________________________________

                                                                                Employee Initials: ________