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, 13 Dearborn Road, Burlington, MA 01803 781-640-9351