WHAT TO EXPECT Youth Night Registration FormStudent Name * Student Email * Student Phone * Student Age * Student Date Of Birth * Parent/Guardian Name * Parent/Guardian Phone * Parent/Guardian Email * Parent/Guardian Address * Emergency Contact * Emergency Contact Relationship to Child * MotherFatherLegal GuardianGrandparentOtherEmergency Contact Phone * Medical Conditions/Allergies * Medications * other-information-we-should-know * Transportation Permission * YESNOPhoto Release Permission * YESNOSelf Check-Out Allowed * YESNOAuthorized Pick-Up Person Name * Authorized Pick-Up Person Phone * 2nd Authorized Pick-Up Person Name 2nd Authorized Pick-Up Person Phone I certify that the information above is accurate and authorize emergency medical care if needed. * YESNOParent/Guardian Signature * Date of Authorization * Thank you for submitting form..! CONTACT climbers@mountainfaith.org (608) 356-1804 E11104 Moon Rdbaraboo, WI 53913 Chat on WhatsApp
