Activity Participation Agreement
Activity Information:
Sponsoring Organization: Address: Activity Coordinator: Description of activity: Date(s) and location of activity:
Participant Information (To be completed by participant or authorized guardian)
Name of Participant:
(please list all children here)
Name of Parent/Guardian: Address/Telephone: Name/number of emergency contact: List allergies or medical conditions: Is sponsor authorized to approve medical treatment? Is participant covered by personal/family medical insurance? If yes, name/number of insurer: Policy or group number:
Yes Yes
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