Event Registration

CLOWN HEART: Prismatic Clown

Personal Information

Number of Attendees: First Name: Last Name: Nickname Preferred Gender Pronoun: Birth Date: / /

Contact Information

Country: Address: City: State: Zip: - Email: Cell Phone

Additional Information

Please write a short description of yourself Have you done volunteer and social work in the past? How about as a clown? Please describe. Do you have any Health Concerns? Or Special Dietary Restrictions? Please include any Food Allergies. Would you be comfortable rooming with someone of another gender? Dietary Preference (choose 1 option and mention exceptions/allergies above) Languages Spoken What is the best way and time to reach you? How did you hear about this?

Travel Information

From which city will you depart? Do you need a ride from Gesundheit Staff from the airport or train station?

Yes

If you are traveling by train, what is your train number? What is your arrival time into White Sulphur Springs? From which direction? If you are traveling by plane, what airline are you flying with? What is your flight number? What is your arrival time into Lewisburg Airport?

Emergency Contact Information

Emergency Contact Name Emergency Contact Relationship Emergency Contact Phone Number Emergency Contact Email

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Neon CRM by Neon One

Patch Adams MD & Gesundheit Institute, P.O. Box 307, Urbana, IL 61803