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2. Primary Contact*
3. Phone Number*
5. Participants
   Please list the names and ages of all family members attending the event. If less than five family members are attending, list N/A in the extra fields.
7. Participant Name*
8. Age*
10. Participant Name*
11. Age*
13. Participant Name*
14. Age*
16. Participant Name*
17. Age*
19. Participant Name*
20. Age*
22. Medications*
    List any prescription and non-prescription medications currently being taken and the family member to whom it applies. If none, list N/A.
24. Allergies*
    List any allergies and the family member to whom it applies (include food, medication, insect sting/bites, etc). If none, list N/A.
26. Medical Conditions
    List any medical conditions and the family member to whom it applies (asthma, chronic back issues/surgery, heart problems, stroke, migraines, seizures, diabetes, etc.) If none, list N/A.
28. Other Information*
    Describe any physical and/or behavioral conditions that will require special assistance during the event. If none, list N/A.
30. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
32. Electronic Signature*
33. Date*
    Date
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35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field