Summer at Heights

Primary Contact First Name

Primary Contact Last Name

Primary Phone

Address

City

Country

State / Province

Zip / Postal Code

Email

Password:

My child is subject to the following health issues

Please list all known allergies for this participant

Indicate Agreement
(Required)

Yes
No

I understand that SUMMER AT HEIGHTS accepts NO RESPONSIBILITY FOR MEDICAL LIABILITY. I will be billed for any medical expenses incurred
(Required)

Yes. I read and understand the Medical Liability statement

Indicate agreement
(Required)

Yes
No

Physician's Name

Physician's Telephone Number

The following items are in progress.