CITY LOCALS APPLICATION - SECTION 5


 SIGN & SUBMIT

A “RESPONSIBLE PARTY” INDICATES THE INDIVIDUAL(S) WHO MAY BE CONTACT IN THE EVENT OF EMERGENCY OR OTHER CONCERN AS IT PERTAINS TO YOUR PARTICIPATION IN THE SOUTHWIND FIELDS CITY LOCALS PROGRAM.  THIS PERSON MAY BE A PARENT, ADULT SIBLING, INVOLVED FAMILY MEMBER, LEGAL GUARDIAN, OR OTHER NAMED, INVOLVED INDIVIDUAL.  THIS PERSON MAY BE GIVEN INFORMATION REGARDING YOUR PARTICIPATION IN THE PROGRAM AS DEEMED APPROPRIATE FOR YOUR SAFETY AND INDEPENDENCE. 

IF YOU DO NOT WISH FOR ANYONE TO BE CONTACTED REGARDING YOUR PARTICIPATION IN THE PROGRAM, PLEAE LEAVE THAT SECTION BLANK.

RESPONSIBLE PARTY *
RESPONSIBLE PARTY
(i.e. mother, father, sister, friend, guardian, etc.)
Responsible Party Phone Number
Responsible Party Phone Number
RESPONSIBLE PARTY No. 2
RESPONSIBLE PARTY No. 2
Responsible Party Phone Number
Responsible Party Phone Number
Today's Date *
Today's Date
Today's Date *
Today's Date