Name *

First Name

Last Name

Does the participant experience any of the following medical conditions? Check all that apply

Asthma

Heart Condition

Hearing Limitation

Dizziness or Fainting

Seizures

Hand / Grasping Related Conditions

Shoulder Injury

Emergency Contact Phone

(###)

###

####

Photo Release: I, (participant or legal guardian of participant), give my permission to Hudson Valley Circus Arts to take and include images of myself (or my participating child) on their websites, social media platforms, and in printed or digit promotional materials. *

YES

Address

(Required by NY State During COVID-19)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country