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2. 
4. First Name*
5. Last Name*
7. Address1*
9. Address2
11. City*
12. State*
13. Zip*
15. Date of Birth*
    Date of Birth
16. E-Mail Address*
18. Phone Number:*
20. Emergency Contact*
21. Emergency Contact Phone #*
23. Medical Conditions (if any)
25. Emergency Information Waiver & Release

    In consideration of my participation with GT Connections, I agree to release Georgetown Township, its officers, agents, and employees, whether on a permanent, temporary, or voluntary basis, from all claims, liability, actions, causes of action, and/or damages by the undersigned person, for loss or injury resulting from participation in any Township or GT Connections functions, activities, events, trips, or transportation, whether held on Township property or elsewhere. I understand that I participate in the program at my own risk and I confirm that I have no physical, emotional, or mental conditions that may restrict my participation in the program.  I grant permission to Georgetown Township to obtain any necessary emergency service at my expense should I sustain injuries.

    I have read the release and understand that this is a full final release of all claims for injuries and damages sustained while participating in GT Connections events and I understand the responsibilities I have assumed.

27. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
29. Electronic Signature*
31. Activity Policy

    I understand that I must call GT Connections at least 24 hours in advance to cancel an activity/lunch/trip/etc., that I have signed up for.  If I do not cancel prior to 24 hours, I realize that I will not receive a refund.

33. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
35. Electronic Signature*
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37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit Submit and Print

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