Hot Bread Kitchen Week Zero and Training Waiver

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Contact Information

First Name

"Student" in waiver below

Last Name

"Student" in waiver below

Today's Date

Date of form execution

Age Category

<1919-5555+

Email

Phone

Address

City

State

Zip Code

Allergy Information

Please note: you must disclose any and all known allergies and if necessary, must be equipped during programming with medication if you have been diagnosed.

Do you have any allergies?

YesNo

Please describe your allergies, including the severity of the reaction(s)

Do you require an EpiPen?

YesNoI don't know

Are you able to bring your EpiPen on-site, or do you need support with that?

I can bring my own EpiPenI need help to obtain an EpiPen

Emergency Contact

Please list a person we can contact in case of emergency.

Name of Emergency Contact

Relationship to You

(Mother, brother, spouse, partner, cousin, etc)

Emergency Contact's Phone Number

Contact Information