Saturday, March 7, 2015 12:00 - 4:30 pm Concordia University Gymnasium (6430 NE 27th Ave.) Registration Child One Name * Age * Gender * - Select -MaleFemale Parent/Guardian First Name * Last Name * Email * A confirmation email and further Respite Day information will be sent to this address. Contact Phone Number (xxx-xxx-xxxx) * Emergency Phone Number (xxx-xxx-xxxx) * Mailing Address Mailing Address Line 2 City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP or Postal Code Please indicate what support or services your son/daughter needs to have a successful experience: Important Health Considerations (allergies or medical conditions): Child Two Name Age Gender - None -MaleFemale I authorize my son's/daughter's photo to be taken and used in camp promotional materials. * Yes No NOTE: A signature for authorization will be required at check-in on the date of the event. Upon submission of this form, I hereby register my son/daughter in the Respite Day event. I authorize the staff to administer first aid to my son/daughter in the event that injury or health problem that may occur during their participation. I hereby release and hold harmless the Concordia University Respite Day staff, its employees and students from any and all liability that may arise out of my son's/daughter's participation in this event. I acknowledge that I am responsible for any and all medical expenses due to my son's/daughter's illness and/or injury. Disclaimer: Concordia University Portland has a firm commitment to privacy. We will not share or sell your private information. To learn more about our privacy standards, please click here.