Canyon Springs Club Registration Form
Please make checks payable to Canyon Springs. Please submit checks to club leader on the first day of attendance.
NO CASH ACCEPTED - CHECKS ONLY!
Email address *
Participant's Name: *
Your answer
Homeroom Teacher *
Your answer
Medical Conditions/Allergies: *
Your answer
Can be photographed & posted on CS Website
How does the participant get home *
Parent/Guardian: *
Your answer
Home Address: *
Your answer
Home #: *
Your answer
Work #: *
Your answer
In case of emergency (other than parent) name: *
Your answer
Phone #: *
Your answer
What club are you signing up for? *
Your answer
Insurance Coverage Information
To the best of my knowledge, this student/ participant does not have any health problems that would be harmful to him/her while participating in this community schools program. Be it known that i, the undersigned parent/guardian/participant of the named student/participant, do hereby give and grant unto the instructor my consent and authorization to render such aide, treatment or care to said participant as, in the judgment of the instructor, may be required on an emergency basis, in the event said participant should be injured or stricken ill, it is hereby understood that the consent and authorization hereby given and granted are continuous, and are intended by me to extend through the length of the program. If emergency service involving medical action or treatment is required and the parents nor guardians can be contacted, I hereby consent for the participant to be given medical care by the doctor selected by the instructor. (Participant must have medical insurance to participate.)
Insurance Coverage Company: *
Your answer
Policy Number:
Your answer
Group Number: *
Your answer
Parent/Guardian/Participant (if over 18) Signature: *
Your answer
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