St. Louis CMTA Youth Outing

St. Louis CMTA Youth Outing Registration Form

Parental Contact Information

Parent's First Name: (required)

Parent's Last Name: (required)

Parent's Mailing Address: (required)

City: (required)

State:
-- select state --AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming

ZIP: (required)

Parent's Email: (required)

Parent's Mobile Phone: (required)

Parent's Alternate Phone:

Emergency Contact Phone: (required)

Emergency Contact Name: (required)

Will you be attending the St. Louis Patient/Family Conference?
YesNo

Will you be staying at the Marriott?
YesNo

CMT Youth Information

Child's First Name: (required)

Child's Last Name: (required)

Child's Age: (required)
-- select age --101112131415161718

Child's Gender: (required)
-- select gender --MaleFemale

Child's Email (if applicable):

Child's Mobile Phone (if applicable):

Health/Diet Information

Does your child have CMT? (required)
yesno

Is your child able to stand without assistance? (required)
yesno

Is your child taking any medication that will need to be administered during the outing? (required)
yesno

If yes, please explain:

Does your child have allergies? (required)
yesno

If yes, please explain:

Will your child be bringing an epipen?
yesno

Any other medical/dietary information we need to know?

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