History Encounters – LaCanada Elementary February 6-10, 2023 "*" indicates required fields 1Participant2Medical3Lunch4Agreement Product ID is required. Please check the referring link. If you need assistance, please contact us. Application Page for From To Participant InformationSelect an Option from below* Student Chaperone Name* First Last Date of Birth* MM slash DD slash YYYY Gender* Male Female Email* Cell Phone*Home Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Postal Code Grade*Kindergarten123456789101112T-Shirt Size*Select T-Shirt SizeYouth LargeAdult SmallAdult MediumAdult LargeAdult XLAdult 2XLAdult 3XLParents/Emergency ContactsYou must add at least one emergency contact for the applicant.Related Contact Name First Last Cell Phone*Email Relationship to ApplicantPlease select...FatherMotherParentAuntUncleGrandparentSpouseIs Emergency Contact? Yes No Add another Contact Add another Contact Related Contact Name First Last Cell Phone*Email Relationship to ApplicantPlease select...FatherMotherParentAuntUncleGrandparentSpouseIs Emergency Contact? Yes No Participant Medical InformationConditions*NoneBleeding/Clotting disordersConvulsionsDiabetesFrequent ear infectionsHeart defect/diseaseHepatitisHypertensionMononucleosisAllergies*NoneAsthmaHay FeverInsect StingsIvy poisoning, etc.Other DrugsPenicillinFood AllergiesOther Medical IssuesDoctor's InformationDoctor's Name* Doctor's Phone*Insurance InformationInsurance Company* Policy/Group number* Expiration Date MM slash DD slash YYYY Dietary Limitations* None Gluten Free Vegetarian Vegan Other Choose a Philly Style Lunch* Cheesesteak Chicken Cheesesteak Veggie Sandwich Steak w/ No Cheese Chicken Steak w/ No Cheese Release and Permission Agreement*1. The undersigned is a parent or legal guardian legally authorized to enter into this agreement on behalf of the minor named above. 2. Release and hold harmless the FFVF from any and all claims, damages, or losses of any kind, including any attorney fees, in connection with the busing service provided by the FFVF. 3. That the FFVF is not responsible for any personal belongings or items brought to FFVF, including all activities related there to, by the minor named above which may be lost broken missing or stolen. 4. I am fully aware of the risks inherent in various program activities, and agree to hold harmless and will not hold the FFVF its instructors, employees, associates, affiliates, or any other entity or person associated with the FFVF liable for any injury or loss that will/ may occur during any FFVF program. 5. I give my permission for the minor child named above to participate in field trips, and overnight activities, utilizing bus transportation provided by the FFVF. 6. I give permission for the FFVF to use pictures of the minor named above in any advertising promotional material. 7. The FFVF, its instructors, employees, associates, agents, servants, affiliates, or any other entity or person associated with the FFVF is permitted to secure emergency medical/surgical treatment for the minor child named above that may be deemed necessary under circumstances. I have read and agree to the terms listed above.HiddenProgram Costs Does not include air transportationHiddenProgram Costs HiddenNon-Refundable Deposit HiddenDeposit Due Date HiddenAir Fare Costs HiddenAir Fare Due Date CommentsThis field is for validation purposes and should be left unchanged.
