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Due North Wed Night on Wednesday, September 6, 2017 @ 6:30 PM

*Date of Birth:
Current School:
*Grade (Must be a current 6th Grader to attend):
Medical or Physical Restrications:
Medications: :
Name of Church your child regularly attends:
T-Shirt Size:
*Name and Phone Number of person bringing student to Due North:
*Parent Name:
*Parent Phone:
*Parent/Family Email:
*Parent/Family Address:
PARENT/GUARDIAN: I hereby consent to any medical treatment deemed necessary during my child's participation in Due North. I assume the risk and financial responsibility for any injury, illness or liability resulting from my child's participation.:
*Medical Release Consent - Type your name here:
PARENT/GUARDIAN: I grant permission for my child to participate and appear in video or audio recordings, films, photographs, written articles, or on websites and social media sites. This consent includes the use and editing of my child’s image, voice and name in media projects by Due North or ChangePoint for print or social media. :
*Photo Consent-Please type your name: