EmailMe Form - 2012 Kick Butts Day Registration

Contact Information

Name of group *

Sponsoring organization/school *

Adult contact *

First Last

Adult contact address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Adult contact email *

Adult contact phone *

### - ### - ####

Extension

Things we should know

Does anyone in your group have special dietary needs? *

Yes

No

If yes, please explain. We will do our best to accommodate your needs.

Bus Transportation:

We will be providing regional bus transportation to and from the event for groups that register by the March 2nd deadline. (This doesn't apply to Chapters in Boston..)

Please indicate whether your group will use bus transportation from your region. *

Yes

No

Participants:

Each group is guaranteed space for 7 people to attend, one of which must be an adult chaperone. However, we anticipate that there will be additional room to accommodate more people from each group, so we encourage you to put people on the waitlist if more than 7 people from your group want to participate in Kick Butts Day!

Participant Information

Adult chaperone: Name

First Last

Adult contact cell phone *

### - ### - ####

For contacting you on the day-of

Adult chaperone: Email

Participant 1: Name

First Last

Participant 1: Email

Participant 1: Age

Participant 1: Youth or Adult

Participant 2: Name

First Last

Participant 2: Email

Participant 2: Age

Participant 2: Youth or Adult

Participant 3: Name

First Last

Participant 3: Email

Participant 3: Age

Participant 3: Youth or Adult

Participant 4: Name

First Last

Participant 4: Email

Participant 4: Age

Participant 4: Youth or Adult

Participant 5: Name

First Last

Participant 5: Email

Participant 5: Age

Participant 5: Youth or Adult

Participant 6: Name

First Last

Participant 6: Email

Participant 6: Age

Participant 6: Youth or Adult

Waiting List:

If there are more youth and adults who want to Attend the Kickoff and Training beyond the five spaces above, please list the names and information (including age, email and whether they are a “youth” or “adult”). Any additional registration requests from your group will be placed on a waiting list and immediately notified as space becomes available. We will do our best to include everyone who wants to come!

Waiting List 1: Name

First Last

Waiting List 1: Email

Waiting List 1: Age

Waiting List 1: Youth or Adult

Waiting List 2: Name

First Last

Waiting List 2: Email

Waiting List 2: Age

Waiting List 2: Youth or Adult

Waiting List 3: Name

First Last

Waiting List 3: Name

Waiting List 3: Email

Waiting List 3: Age

Waiting List 3: Youth or Adult

Important:

The Consent Forms are required for ALL the youth who are attending. Please download the form at www.the84.org/2012kickbuttsday and mail or fax to us by Friday, March 2, 2012.