Name*

Phone*

Email*

Team or School Name*

Birthday mm/dd/yyyy*

Today's Date mm/dd/yyyy

Emergency Contact Name*

Emergency Phone Number*

Emergency Contact's Relationship To You*

Shirt Size*

Please Describe Any Conditions Checked Above and List Any Medications Taken For The Condition

By checking this box I am confirming that all information I have entered is accurate and complete, and I agree to hold Driven For Life Inc. harmless of all relevant personal information not disclosed. By checking this box I agree to comply with the instructions and directions of Driven For Life Inc.'s staff members during the program. Furthermore, I agree to indemnify, defend and hold Driven For Life Inc. and its officers, directors, affiliates, employees, staff, volunteers and faculty harmless from any injury to my safety and well-being, including all losses, damages, costs and expenses, including attorney's fees, for any such injury to my safety and well being.

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