Defying the Impossible Registration

Defying the Impossible Registration
Part A: STUDENT INFORMATION
City
State/Province
Zip/Postal
Country
Part B: PARENT INFORMATION
The information must be provided. Please provide a minimum of TWO emergency contacts. Only adults indicated on this form will be allowed to pick up your child from the program. Proof of identification will be requested by staff.

First Emergency contact

City
State/Province
Zip/Postal
Country

Second Emergency contact

City
State/Province
Zip/Postal
Country

Third Emergency contact

City
State/Province
Zip/Postal
Country
Part C: MEDICAL INFORMATION
Part D: WAIVERS, DISCLAIMERS & CONSENT