Carabiner's Fairfield Registration Form


The following information will be used to complete a document that you will read and then sign. Please complete the following form to create the document. You can preview the document you will be signing





This is the person participating in any activities. If the participant is a minor, the form must be signed by a parent or legal guardian.
Participant Name

First Name *

Middle Name

Last Name *
Date of birth of the participant, not the person signing the waiver.
Participant Date Of Birth *
Email Address

Participant Address

Address *


City *

State *

Zip/Postal *


Country
Phone Numbers *

Cell Phone

Home Phone

Work Phone
Emergency Contact

Emergency Contact First & Last Name *

Emergency Phone *
Medical History
Please explain any medical condition for which you are currently receiving treatment of taking any medication:

Please list any pre-existing medical conditions:

Please list your medical insurance provider, if any:


Electronic Signature Consent  *
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

SAVE INFORMATION FOR ADDITIONAL DOCUMENTS

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