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First name*

Last name*

Email*

Mobile phone*

Second parent or caregiver full name*

Second parent or caregiver phone number*

Address

Emergency Contact- full name*

Emergency Contact- phone number*

Photo permission?*

Do you give permission for photos to be taken of your child?

Social Media permission?*

Do you give permission for the occasional use of a photo with your child in it on social media?

Password*

Confirm password*

Pledge Request for Acceptance and Recognition as Member

By ticking this box, I accept the . By ticking this box, I acknowledge that I am selecting the Treasurer to control the common fund. By ticking this checkbox I acknowledge I am signing to become a member of Essentia Civitas Association and the Adventurers Members Class.