Parent/Caregiver's Name
*
First Name
Last Name
Parent/Caregiver's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent/Caregiver's Email
*
Parent/Caregiver's Cell Phone
*
(###)
###
####
Warrior's Name
*
First Name
Last Name
Warrior's Birthday
*
MM
DD
YYYY
Warrior's Hospital
*
Warrior's Diagnosis
*
How many people will need to rent roller skates?
*
Please list all family members that will be joining you and their relationship to your warrior
*
How did you hear about this event?
*
Additional Comments
SMS/Email Opt-In
Photo Consent
COVID Waiver
*
Attendance Policy
*
Rules of Conduct
*
Thank you! You will receive an email prior to the event with more information.
If you need to make any changes or can not attend the event please contact Tiffanie, at tiffanie@amandahope.org.
