Sign Up – MyNextLvl

Guardian Consent

We need to know if you have guardian support and to specify who they are.

*Are you over 18? If YES, click to the next page.

Guardian Full Name:

Address:

Email Address:

Date of Birth:

Emergency Contact Information

Name:

Relationship:

Medical Information:

Name of Doctor/Healthcare Provider:

Does your child experience any condition(s), condition(s) requiring medical treatment, or take any medications? If yes, please specify:

I give permission for my child use and partake in MyNextLvl.
I give permission for medical attention to be sought in case of emergency.
I give permission for the use of my child’s contact information to only be used in emergency situations.
I give permission for my child to communicate directly with providers and healthcare facilities through MyNextLvl.

Current Date:

Signature:

Relationship:

Full Name:

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