2013 Respite Day Registration Form

First Name

Last Name

E-mail Address

Phone (Home)
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Phone (Emergency Contact)
() -

Mailing Address (include PO Box or apartment number if applicable)

Mailing Address Line 2

City

State
Choose... Alabama Alaska American Samoa Arizona Arkansas California Canal Zone Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Military - Americas Military - Europe Military - Pacific Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Please indicate what support or services your son/daughter needs to have a successful experience:

Important Health Considerations (allergies or medical conditions):

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.