Diffuse in York Registration Form Participant's Name * First Name Last Name Location I will attend * The Well Worship Center - 155 S Hartley St. York, PA 17401 Participant's Date of Birth * MM DD YYYY Parent/Guardian's Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country I understand that I will have to sign a release form on the first day of class. * Yes No Emergency Contact Name * First Name Last Name Emergency Contact Phone * (###) ### #### Today's Date * MM DD YYYY Thank you for registering for Diffuse in York!
