Class Registration

Name:               
Street Address:    
City:                    State:  Zip Code:
Phone (with area code):     
Email address:   
Troop:        Council: 

Guardian/Emergency Information
Parent/Guardian Name:       
Home Phone with Area Code:                      
Work/Cell Phone with Area Code:    
 

Emergency Contact Name:    Relationship:
Home Phone with Area Code:                      
Work/Cell Phone with Area Code:    

Does the participant have a history of or currently have any physical limitations that might prevent him/her from fully participating in any classes?  Yes  No
If yes, please describe below.  If none, state "NONE"

Please list any special medications, allergies to food or drugs or any other pertinent medical information.  If none, state "NONE"