Participant's Information

State / Province*
Confirm Email*
Date of Birth (mm/dd/yyyy)*
Do you have any special needs (disabilities, medical conditions) that HCM should be aware of? If so, please specify.*
Do you have any allergies (foods, bees, latex, etc)? If so, please specify.*
Do you have any emergency medications (Inhaler, Epi Pen, Etc.) that you might need HCM staff to administer? If so please specify.*

Parent/Guardian Information

Parent/Guardian - First Name*
Parent/Guardian - Last Name*
Parent/Guardian - Relationship to Child*
Parent/Guardian - Phone*
Parent/Guardian - Street Address*
Parent/Guardian - City*
Parent/Guardian - State*
Parent/Guardian - Zip Code*

Emergency Contact

Your Emergency Contact must be a different person than your the one you listed in the Parent/Guardian section above.

Emergency Contact - First Name*
Emergency Contact - Last Name*
Emergency Contact - Relationship to Child*
Emergency Contact - Phone*
Emergency Contact - Street Address*
Emergency Contact - City*
Emergency Contact - State*
Emergency Contact - Zip Code*
Additional Comments

Security Code