Events

Participant's Name*
First Middle Last
Date of Birth*
Month
Day
Year
Age of patient*
Patient or Sibling
- Patient
- Sibling
If sibling, who are they a sibling to?*
Age of sibling*
Shirt Size*

Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email

Mother/Guardian Name*
First Last
Phone
Father/Guardian's Name
First Last
Emergency Contact*
First Last
Emergency Contact's Phone*

Special Needs?
Does your child have any food allergies?
Is your child taking any medications? If yes please explain any we should be aware of..
Does your child have any emotional and/or physical limitations that would hinder him/her from participating in any activities? If so, explain.
Please attach a photo of your child you would like to be used for their CNM ID badge.
Accepted file types: jpg, jpeg, png, gif.

I, parent or legal guardian gives consent for my child to be photographed, filmed, and/or interviewed and hereby give permission that these photographs, films, and other information may be used for various materials for CCFNM such as newsletters, brochures, flyers, videos, website, Facebook and other materials that may be created or implemented at future dates.*
- Agree
- Disagree
I, parent or legal guardian gives consent for my child to be photographed, filmed, and/or interviewed and hereby give permission that these photographs, films, and other information may be used for various materials for CCFNM such as newsletters, brochures, flyers, videos, website, Facebook and other materials that may be created or implemented at future dates.
I, parent or legal guardian fully understand that for my child's safety and the safety of others, my child must follow all rules of the Central New Mexico Community College and those of Children's Cancer Fund of New Mexico chaperones.*
- Agree
- Disagree
I, parent or legal guardian fully understand that for my child's safety and the safety of others, my child must follow all rules of the Central New Mexico Community College and those of Children's Cancer Fund of New Mexico chaperones.
I, parent or legal guardian understand that disrespectful or disruptive behavior (including but not limited to name calling, use of offensive language, and any behavior that could result in harm physical and/or emotional to others) will not be tolerated. First infraction will result in a verbal warning. Second infraction, CCFNM will notify parents/guardian and ask that their child be picked up immediately.*
- Agree
- Disagree
I, parent or legal guardian understand that disrespectful or disruptive behavior (including but not limited to name calling, use of offensive language, and any behavior that could result in harm physical and/or emotional to others) will not be tolerated. First infraction will result in a verbal warning. Second infraction, CCFNM will notify parents/guardian and ask that their child be picked up immediately.
I, parent or legal guardian of the applicant asks for permission for my child to attend the College Day at the Central New Mexico Community College. I will not bring any action whatsoever upon any grounds against the Central New Mexico Community College and/or Children's Cancer Fund of New Mexico, their agents or servants for any wrongful death, injury (physical or emotional), or property damage that may occur as a result of attending the College Day Event. I fully hold the CNM and Children's Cancer Fund of New Mexico and their agents and servants harmless from any such death, injury, or property damage.*
- Agree
- Disagree
I, parent or legal guardian of the applicant asks for permission for my child to attend the College Day at the Central New Mexico Community College. I will not bring any action whatsoever upon any grounds against the Central New Mexico Community College and/or Children's Cancer Fund of New Mexico, their agents or servants for any wrongful death, injury (physical or emotional), or property damage that may occur as a result of attending the College Day Event. I fully hold the CNM and Children's Cancer Fund of New Mexico and their agents and servants harmless from any such death, injury, or property damage.
Digital Signature (Please type name)*

I have read, agree, and provided accurate information for my child.

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