Winter ActivitiesRegistration Form Participant's Information Name * First Name Last Name Email * Phone * (###) ### #### Date of Birth * MM DD YYYY Gender * Female Male Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Does the participant live at home, independently, or in a group or shared living arrangement? * Agency/Provider Name Primary Contact Emergency Contact * First Name Last Name Emergency Contact Relationship Emergency Phone Number * (###) ### #### Does the participant have any mobility, verbal or auditory challenges that we should be aware of? If yes, please explain so we can make appropriate accommodations. * Select Activity - Check calendar for specific dates > Choose one (1) activity per time block. NOTE: Weather-related cancellations will be posted on our Facebook page. 10:00 AM Drumming Arts & Crafts 11:00 AM Cooking Yoga 12:00 PM Basketball Parent/Guardian/Care Provider Participation Agreement Please read and acknowledge the following: * I am the parent/guardian/care provider of the participant above, who will be participating in the activity of organized and run by the Cape Cod Challenger Club. I have read and understood the terms and the Cape Cod Challenger Club Parent/Guardian/Care Provider Participation Policy. I will abide by the organization’s policy to ensure the safety and enjoyment of all the participants, staff and volunteers. Parent/Guardian/Care Provider Participation Policy * I have read and understood the terms and the Cape Cod Challenger Club Parent/Guardian/Care Provider Participation Policy. Electronic Signature * BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE. Date * MM DD YYYY Thank you!
