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Last Name *

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Contact and Participant Information

Parent/Guardian Contact (1): *

Phone (1) #: *

Relation to participant/s (1): *

Parent/Guardian Contact (2)

Phone (2)

Relation to participant/s (2):

Are you in an existing HKA family? * Yes No

HKA Families - We will cross reference your child's medical information with Veracross. Please ensure Veracross is up to date.

Full name of participant (1) *

Date of birth (1) *

Any known allergies/medical conditions (1)

Other things instructor/programme administrator should be aware of (1)

Full name of participant (2)

Date of birth (2)

Any known allergies/medical conditions (2)

Other things instructor/programme administrator should be aware of (2)

Full name of participant (3)

Date of birth (3)

Any known allergies/medical conditions (3)

Other things instructor/programme administrator should be aware of (3)

Full name of participant (4)

Date of birth (4)

Any known allergies/medical conditions (4)

Other things instructor/programme administrator should be aware of (4)

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