Registration, Renewal, and Information Change Please use this form to register as a participant in our classes and events. Registration Step 1 of 4 25% Have you previously registered this year?* Yes No Are you are parent or guardian of the person being registered?? Yes, I am their parent or guardian No, I am registering myself Participant's Name* First Last Email* Do you need to update your information?* Yes No Cell Phone*Home Phone (optional)Work Phone (optional)Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Parent / Guardian Name* First Last Additional Parent / Guardian Name (optional) First Last Relationship to Participant* Emergency ContactPlease indicate another person to call in case of emergency.Emergency Contact Name* First Last Emergency Contact Phone*Do you currently take medication?* Yes No Please list your medications:Drug Sensitivities Allergies Dietary Restrictions Please list any other concerns we should be made aware of:ConsentThe parent or guardian must consent to the releases below. The photo release is optional..Medical Release* I agree.If the participant needs medical treatment while participating, 911 will be called. It is my wish that the treatment is started while efforts are being made to contact me. So that treatment is not delayed, I consent to any medical procedures that the physicians believe are needed, on the understanding that efforts to contact me will continue to be made. I accept responsibility for all costs related to such treatment.Outings Release* I understand.KALEIDOSCOPE OF WNY, INC. does not participate or plan community outings outside the parameters of our class time. While some may enjoy social functions together after classes, it is not part of Kaleidoscope of WNY, Inc.Photo Release* Yes No I authorize my participant’s picture to be taken and posted on social media and/or website. CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
Recent Comments