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Emergency Data Form

PLEASE PROVIDE ALL THE FOLLOWING DATA.  THIS INFORMATION IS VERY IMPORTANT AND USED ONLY IN CASE OF AN EMERGENCY.


           THIS DOCUMENT WILL BE DESTROYED AT THE END OF YOUR CLASS.


First Participant's Name
First Name*
Last Name*
Phone*
Select Gender
First Participant's Date of Birth*
Date of Birth
First Participant's Address
Home Address *
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Second Participant's Address
Home Address *
Third Participant's Name
First Name*
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Third Participant's Address
Home Address *
Fourth Participant's Name
First Name*
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Fourth Participant's Address
Home Address *
Fifth Participant's Name
First Name*
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Fifth Participant's Address
Home Address *
Sixth Participant's Name
First Name*
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Sixth Participant's Address
Home Address *
Seventh Participant's Name
First Name*
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Seventh Participant's Address
Home Address *
Eighth Participant's Name
First Name*
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Eighth Participant's Address
Home Address *
Ninth Participant's Name
First Name*
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Ninth Participant's Address
Home Address *
Tenth Participant's Name
First Name*
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Tenth Participant's Address
Home Address *
Mobile Phone Number
Mobile Phone Number *
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Emergency Contact's Relation to Participant
Current Medications
List current Medications if none please put N/A in field *
Additional Medical Information/Existing Conditions *
Make, Model, & Color of vehicle you are driving
Vehicle Information *
Travel or Class Partner *
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Select Gender
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Address
Home Address *
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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