Teen Name *

First Name

Last Name

Teen Phone *

(###)

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Parent/Guardian Name *

First Name

Last Name

Phone *

(###)

###

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Parent/Guardian Consent *

I give permission for above mentioned person to participate in the CTeen Purim Party Bus. I release CTeen Phoenix, its officers, agents, employees, staff, and volunteers from any and all liability of any kind whatsoever for any loss or injury to arising from 's participation in the activities of the CTeen Phoenix's Purim Party Bus.

I agree

I do not agree.