One moment please...
Taste of Independence Registration

Wed. August 10, 2022

9:30am-1:30pm

*

First Name
Last Name

*

*

*
*

First Name
Last Name

First Name
Last Name

First Name
Last Name

First Name
Last Name

First Name
Last Name

First Name
Last Name

First Name
Last Name

First Name
Last Name

First Name
Last Name

First Name
Last Name

*
I give permission for the people listed on this registration to have their picture or video taken a the Chautauqua Children's Safety Education Village and to have these photos or videos as a part of a press release, on our website, in any media including Facebook, Instagram and other social media sites, on television, in videos created to display our classes for advertising purposes. I confirm that I am the legal parent or guardian of the child on this application form.