Enrollment FormInterested in signing up? Fill out some info and we will be in touch shortly! Name of individual needing services * First Name Last Name Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Parent/Guardian Information Name * First Name Last Name Address (if different) Address 1 Address 2 City State/Province Zip/Postal Code Country Guardian/Parent Email * Parent/Guardian's Phone * (###) ### #### Backup Release Contact Information If I'm unable to pickup my child, the child may only be released to this person. Name of Backup Release * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Emergency Contact Person Persons to contact in the case of an emergency when parent or guardian cannot be reached. Name * First Name Last Name Emergency Contact Phone (###) ### #### Additional Information Allergies * List all known allergies for individual if applicable EMERGENCY MEDICAL AUTHORIZATION * Should my child suffer an injury or illness while in the care of TRAC ACTIVITIES and the facility is unable to contact me (us) immediately, TRAC ACTIVITIES shall be authorized to secure such medical attention and care for the child as may be necessary. If an accidental injury should occur, TRAC ACTIVITIES is not responsible for any expenses related to such injury. I have read and agreed to the terms above in regards to the emergency medical authorization Thank you!
