4-H Up All Night Registration Form


Name: ____________________________________________________


Emergency Contact Numbers (for December 5th and December 6th)


Name: ____________________________________Phone #_________


Name: ____________________________________Phone #_________


Do you have any allergies, current medical conditions, or are 
taking any medications we should be aware of?  If Yes, please list

____________________________________________________________

____________________________________________________________


Will you be staying all night? Yes___ No___


Who will be picking you up? ________________________________


Who else may pick you up? (You will only be released to those listed below).

_____________________________________________________________


_____________________________________________________________

 
Parent Name (please print)___________________________________


Parent Signature _________________________________Date_______


Please bring with you to the Up All Night