Douglas Mnt. Registration

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Email *

Name of Participant *

Participant is a: *

student (grade 6-12)

young adult (high school grad or older)

adult chaperone

Insurance information. Please include the type of insurance (MaineCare, Aetna, etc.) as well as the ID number. *

In case of emergency, please contact (Name & number - with area code.) *

Emergency contact #2 (Name & number - with area code.)

Does the participant have any medical conditions, including allergies, that we should be aware of? If yes, please explain.

By submitting this form, you the parent of the above named participant or the adult participant named above agree to accept all liability for participation in this event including, but not limited to, the possibility of sprains, fractures, and Covid-19. *

Yes

No. (If no, please contact us at Maine.nyi.youth@gmail.com.)

A copy of your responses will be emailed to the address you provided.

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