Echo Enrichment Center

a place for all ages and abilities

Echo Enrichment Center New Teen/Adult Registration

Participant's Name__________________________________________________________________________________

Date Of Birth________________________________________Male/Female__________________________________

Address__________________________________________________________________________Apt.#________________

City_____________________________________________Zip Code_______________E-mail________________________

Home Phone_____________________________________________Cell Phone___________________________________

Parent/Guardian______________________________________________________________________________________

Emergency Contact Person________________________________________Relationship__________________

Home Phone___________________________________________Cell Phone______________________________________

Food Or Seasonal Allergies ?__________________________________________________________________________

Food Limitations?___________________________________________Physical Limitations?_________________

Medications ?_______________________________________________Fears?_____________________________________

Does Participant Wander Off?________________________________________________________________________

Other Important Information?_______________________________________________________________________
Photo Release----I do/do not grant permission for the above participant to be photographed for
news or program publication. We would never include names in any photo for publication.

Parent/Guardian signature___________________________________________________________________Date________________

Participant Signature (if over 18)____________________________________________________________Date_______________
               Echo Enrichment Center, 14 Lexington Street, Burlington, MA 01803 781-640-9351