Convention - Adult Form | Colorado DeMolay

THE FUTURE BEGINS HERE! | Find Out How | Ages 9-11?

Adult Registration - Colorado Convention 2022

Name

Chapter/Jurisdiction/Position/Title for Introduction

Phone

Address

Shirt Size

Awards and Honors received

Amount Per Room

Dinner Choice

Release

Release Statement

I hereby release Colorado DeMolay from all responsibility and liability for any illness or injury that I may sustain during this activity.

I hereby release Colorado DeMolay from all responsibility and liability for any illness or injury that I may sustain during this activity. In the event of an emergency, I hereby authorize an adult leader of this activity as agent for me, to consent to any x-ray examination, medical, dental or surgical diagnosis, treatment and hospital care advised and supervised by a physician, surgeon, dentist (as appropriate), licensed to practice under the laws of the state where services are begin rendered, either at a Doctor's office or in any hospital.

Electronic Signature

Sign Date

Emergency Information

Emergency Phone #1

Emergency Phone #2

Allergies

Medications Currently Being Taken

Physical Handicaps

Medical Insurance Provider

Name of Policy Holder

Policy Number

Agreement of Guidelines and Waivers

Waiver Statement

I understand that a physical copy of waiver forms required for any event must be scanned and turned in as part of my registration

I have read and agree to the guidelines

I have provided current and accurate information

I have read, understand, and agree to all required release waivers.

I Accept

By selecting "I accept" you consent to be bound by all conditions and terms. You also agree that your electronic signature throughout this form will serve as the legal equivalent of your manual signature.

Final Electronic signature

Electronic Signature acceptance date