Skaters Name *

Date of Birth *

Street Address *

City/State *

Zip Code *

Skaters Phone *

Emergency/Health Issues:
In case of emergency, please notify (if minor/child participant, provide parent’s information or Guardian, as appropriate).

Parent/Guardian Name *

Relationship *

Parent/Guardian Phone *

Parent/Guardian Email *

Any medical, psychological, or behavioral conditions we should be aware of (bee stings, food allergies, etc.)? *

1. Are there any medical or health factors or limitations that might affect Riders performance in the activity?
YesNo

2. Is Rider taking any medications or have a condition that may affect Riders safety or performance in the activity?
YesNo

In case of injury or emergency, I for myself and/or participant (if participant is minor/child), and my personal representatives, heirs and assigns, (severally and collectively “I” for this registration form) give permission for an activity representative to call 911 and transport participant to a hospital. I shall inform Citadel Skate Trips, in writing, of any medical or health conditions of participant that occurs or develops and which could affect participant’s safety, performance or participation in or throughout the activity.

Please download, sign, attach and send (or bring with you on Skate Trips) the Risk & Liability Waiver to: info@citadelskateboarding.org. If you have filled out a Waiver for previous Skate Trips, you DO NOT need to fill out another one.

Signature of participant or, if minor, of parent/guardian: