Wednesday Night Live
If you or your child would like to participate in this event as a Participant, please complete the following form.

(If you are under 18, please have your parent or guardian complete the form.)
Personal Information
*Participant's First Name:
*Participant's Last Name:
*Preferred Name for Name Tag:
*Parent/Guardian Name:
*Address:
*City:
*State:
*Zip:
*Cell Phone:
(555-555-5555)
*Email:
*Gender:
*Current Grade:
(Enter the grade that the child is in for the 21-22 school year.)
*Birthday:
(MM/DD/YYYY)
*Allergies, Medical, & Special Needs:
(Leave Blank if None)
*Emergency Contact Name (1):
*Emergency Contact Phone (1):
(555-555-5555)
Emergency Contact Name (2):
Emergency Contact Phone (2):
(555-555-5555)
*Authorized Pickup #1:
*Authorized Pickup #2:
*T-Shirt Size:
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