Please check that the below information is correct and click ‘Next’.
*Select who you are and click ‘Next’ .
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Note: If you do not have an Adult Chaperon Application/Verification Form, please contact your group leader or firstname.lastname@example.org
Other Food Allergies:
Current Medication and Dosage (prescription and over the counter):
Medical History/Chronic Medical Problems (e.g. diabetes, epilepsy):
To sign,left-click anywhere in the box above and hold down while using your mouse or trackpad to draw your signature.Click the 'Clear Signature' button to start over.