Winter Blast! 2007 Participant Registration Form

Please fill out the form below completely. The Form will not successfully complete if any of the required portions of the form are left blank. Click on the Display Form button to send your information to Holy Name of Jesus and to print out a copy of your Participant Registration Form. A Parent or Guardian must sign the form. Please mail or drop off the signed form to the HNOJ Parish Office with the registration fee to ensure the participant's spot at Winter Blast. Please contact Nate Reinhardt via e-mail or phone: (763) 746-8194 with any questions regarding this event or the registration process. Thank you!

Participant's name: (required)

Parent's Email: (required)

Participant's Email: (required)

Participant's Birth Date: (required)

Male
Female

Grade in School: (required)

Parent/Guardian's Name: (required)

Home Address: (required)

City: (required)

Zip: (required)

Home Phone: (required)

Business Phone and/or Cell Phone:

Emergency Contact Information: (required)
Emergency Contact's Name:

Emergency Contact's Phone Number:

Medical Information:
Medication my child is taking at present:

Allergies:

Family Health Plan carrier number:

Family Doctor:

Family Doctor's Phone Number:


Please use your browser's print button
on the next page to print out your completed
registration form. The completed form MUST
be printed, signed and returned to the Parish Office
with payment in order to hold the participant's spot
in Winter Blast! 2007. Please contact Nate Reinhardt either
via e-mail or phone: (763) 746-8194 with any questions
regarding the registration process. Thank you!

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