You R You Credit Card Registration Form | United Way of Washington County East

Parent Contact Information:

First Name:

Last Name:

Email:

Phone:

Relationship to Child:

Are you their Emergency Contact?

Do you want to add a second parent?

Yes

No

First Name:

Last Name:

Email:

Phone:

Relationship to Child:

Address

Apt, Suite or Bldg.

City/Town

State/Province

ZIP/Postal Code

Participant Information

First Name:

Last Name:

Gender:

Date of Birth:

Name of School, Fall 2024

Please list any known allergies

Please list any medications the participant is currently taking

Participant Waiver

R ead Through Waiver Here

Please click above to read through our participant waiver, once you've read through it please sign electronically below.

sign

By signing you agree to all terms and conditions within the participant waiver.

Complete Payment

Please register my child for this event:

$75

Credit Card Information: