Teen Group Registration | HeartwoodExpeditions

Fireside Group Registration

Participant First & Last Name

Caregiver First & Last Name

Participant Preferred Name and Pronouns

Caregiver Email

Caregiver Phone Number

Secondary Emergency Contact Name and Phone Number

Does the participant have any known allergies, medical conditons, or past pertinent medical history?

Will the participant come with an epipen or other medications? If yes please specify the reason and the dosage.

Why is participant interested in this group?

Does the participant or caregiver have any concerns about this event?

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My signature below confirms that I have read the Heartwood Expeditions waiver in it's entirety and consent to all permissions and risks identified in the waiver form.

Your Signature

Enter the amount you wish to pay:

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