Participation AgreementParticipation Agreement • October 14th, 2020 • Pennsylvania
Contract Type FiledOctober 14th, 2020 JurisdictionChurch Name: Youth Leader Name: Child’s Name: Home Address: Date of Birth: Parent/Guardian Name: Parent/Guardian Phone: Emergency Contact 1 (name & relationship): Phone: Emergency Contact 2 (name and relationship): Phone: PLEASE LIST ANY SPECIAL INFORMATION, INCLUDING ALLERGIES, DIETARY RESTRICTIONS AND MEDICAL CONDITIONS, BELOW. Insurance Carrier: Group/Policy #: Family Doctor: Address/Phone Number: