Name *
Name
Phone *
Phone
Address
Address
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone *
Emergency Contact Phone
Section
Release: I, the undersigned do hereby release and discharge PPAC from any and all claims for personal injuries. By entering my name below I agree to this release statement.
Release Name *
Release Name
Agree to Use of Images *
I give permission to Presser PAC to use any photographs or media of student in promotional materials, commercials, and on the web site