Caregiver's Name *

First Name

Last Name

Phone

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

School year interested in? *

2023-2024 School Year

Child's Name *

First Name

Last Name

Child's Birthday *

MM

DD

YYYY

Do you agree to the following statement? "I (we), the parent or legal guardian of the above listed child(ren) grant permission for my child(ren) to participate in Prickly Pears and to receive medical treatment if necessary. If I (we), or the listed emergency contacts cannot be reached, I (we) give our permission to the staff to secure services of a licensed physician to provide necessary care, including anesthesia, for our child(ren)'s well-being. I (we) also release and agree to hold harmless Prickly Pears and all its participants and staff from any liability and assume all risk from injury, damage or expenses as the result of participation in Prickly Pears. I (we) also authorize Prickly Pears Staff to administer basic first aid to our child(ren)." *

Yes, I agree

Do you agree to the following statement? "I authorize the use of photos taken during Prickly Pears for purposes of publicity on websites, Facebook pages and/or promotional materials. (We never use names of children in such materials.)" *

Yes, I agree

No, I do not agree