Wednesday Night Educational Series Form

Wednesday Night Educational Series Form

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First Name*:
Last Name*:
Email Address:
Phone Number:
Age*:
Birthday*:
Parent/Guardian Name:
Parent/Guardian Email:
Parent/Guardian Phone Number:
Emergency Contact Name*:
Relation to Student*:
Emergency Contact Number*:
Other information: Please list any of the student’s allergies or any other information it would be helpful to know:
I DO consent to and authorize the use and reproduction by PSL Services/STRIVE of any and all photographs and any other audio/visual materials taken of participant for promotional materials, educational activities, and/or exhibitions*:
Signature of Student if over 18, or guardian*:
Date*: