Event Registration

First Name: Last Name: Number of Attendees: Is your participant a current student or enrolled in a post-secondary program? YES NO Primary Parent/Guardian Name Primary Parent/Guardian Cell # Current Address* (Address, City, State, Zip) Email* Home Phone Secondary Parent/Guardian's Name Secondary Parent/Guardian Cell # Emergency Contact Name* Emergency Contact Number* Family Physician Name & Phone Number MEDICAL RELEASE: It is understood that parents/guardians, their agents will be called upon to give additional authorization if advanced treatments are necessary. In the event that the parent/guardian or their agent is not present, I hereby authorize Autism Society NWPA, or anyone they may designate to authorize treatment for my son/daughter for injuries or illnesses he/she may incur while participating in activities at Autism Society NWPA. I authorize necessary treatment and admission for any hospitalization designated by Autism Society NWPA, or their designate. PHOTO CONSENT: I/we grant permission to all foregoing to use any photographs, motion pictures, recording, or other records of this event for any legitimate purpose. The photos would be used to promote and share on social media to include Facebook, Instagram, and our website. If you have a coupon, please enter code here (case-sensitive):