Cross Bayou

Awakening Date

Awakening Number

First Name

Last Name

Name You Want on Your Name Tag

Email Address

Address

City

State and Zip Code

Birthdate

Parent / Guardian Name

Primary Phone #

Alternate Phone #

T-Shirt Size

Gender Gender Male Female

Have you been informed to expect NO outside contact during the weekend, except in an emergency? Have you been informed to expect NO outside contact during the weekend, except in an emergency? Yes No

Has it been explained to you that all Awakenings are SMOKE FREE events? Has it been explained to you that all Awakenings are SMOKE FREE events? Yes No

Sponsor's Name

Participant's Signature SaveClear

Date

By signing here I give my son / daughter permission to attend this Awakening three day event. SaveClear

Date

New Field

I am the Parent/guardian of

During the event I can be reached at this number

Alternate phone number

Primary Physician's Name

Primary Physician's Phone Number

Insurance Provider

Insurer's Phone Number

Participant's SSN (necessary in case of emergency treatment)

Date of last tetanus shot:

Are there any mediations to be taken during the event? Are there any mediations to be taken during the event? Yes No

List Medications:

List Allergies:

Explain any dietary requirements: