Registration — Sampradaya

Registration & Medical Liability Release Form

Participant

Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Grade in School

New Student

If yes, how did you find out about us?

If other, please specify

Parent/Guardian #1

(If you are 21 and above, please fill in your own information in this area)

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Email

Parent/Guardian #2

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Email

Emergency Contact Information

Name

First Name

Last Name

Phone

(###)

###

####

Relationship

Any Specific Health Conditions

Click HERE for Medical Liability Form