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SAL Release Waiver
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Participant Name
*
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Participant Age
*
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Contact Phone Number
*
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Birth Date
*
MM
/
DD
/
YYYY
Complete Street Address
*
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Mailing Address
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Guardian 1 - Name and Phone Number
*
Your answer
Guardian 2 - Name and Phone Number
Your answer
Guardian Email
*
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Participant Email
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Food Allergies
*
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Drug Allergies
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Medication or Medical Information
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Restrictions, Special Conditions or Medical Treatment
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Physician/HMO Name
*
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Medical Insurance Provider
*
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Emergency Contact Person and Phone Number
*
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Emergency Contact Person 2 and Phone Number
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School Attended and Grade Level
*
Your answer
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