CCLE XXIV Child Ticket

Child first name: *

Child last name: *

Parent first name: *

Parent last name: *

Parent cell phone (for contact at event): *

Emergency contact name: *

Emergency contact phone: *

Child's age at conference: *

Allergies:

Health concerns:

I give permission for photos of my child to be used in CCLE's publications.: * Yes No

Privacy Preference:   Opt-out from being displayed in the public list of attendees.