Adventure Zone

On Line Registration Form

 

 
Registration & Confidential Evaluation Form
(All answers are kept in confidence)
Bold fields indicate required information.

First name:

 Last name:
Address: E-mail:
City: State:
Zip Code: Home Phone:
Work Phone: Cell Phone:
Date of Birth: Sex: M   F
School: Grade in Fall:
Hobbies / Interests:
T Shirt Size:

Parent / Guardian:
(if applicable)
Activity:
Activity Date(s):
Today's Date:
Registration Fee: Deposit Amount:
After submitting this form you can choose payment options.
Health History
Allergies Yes - No Problems Yes - No
Bee stings
-
Epilepsy/
Convulsions		 -
Insect bites
-
Heart Trouble -
Penicillin
-
Fainting Spells -
Nuts
-
Asthma/
Wheezing		 -
Other: Frequent
Stomach Upset		 -
    Hearing Problems -
If there are any disabilities or symptoms we should be aware of, please indicate below: Sight Problems -
Ear Infections -
Bladder /
Kidney Trouble		 -
Heat Exhaustion -
Stroke -