Membership Checkout

Membership Information

You have selected the Youth 3 Pack Registration (Requires Code from 3 Pack Purchase) membership level.

Use this to register each individual youth slot purchased from the 3 pack.

The price for membership is $0.00 now.

Membership expires after 3 Months.

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Account Information

Username

Password

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Email Address

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Full Name LEAVE THIS BLANK

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Character Information

Character Name

Race

For New Characters Only

Class

For New Characters Only

Emergency Information

Physical / Medical Accommodations

List any allergies (medications, food, etc.) , medical conditions, or physical conditions you'd like us to consider when planning the event. Interphaze events involve moderate physical activity over a sustained time period. Please list any accommodations you may require to fully participate in this event. We will make every attempt possible to incorporate the accommodations. In the event your request can’t be accommodated, a representative will contact you to make arrangements specific to your needs.

Emergency Contact Name

Emergency Contact Phone

Date of Birth

Required if participant is under 18

Name of Adult Chaperone

Required for participants under 18

Emergency Medical Treatment Consent

I consent to emergency medical treatment in the event of injury or medical emergency. I have supplied any and all pertinent medical information.

Hold Harmless Agreement

I agree to hold harmless and indemnify the officers, volunteers, staff and owners of INTERPHAZE and CENTRAL COUNCIL, BOY SCOUTS OF AMERICA and NATIONAL COUNCIL, BOY SCOUTS OF AMERICA from any and all liability, loss, damages, costs, or expenses which are sustained, incurred or required arising out of the actions of the undersigned in the course of Interphaze, or an event sponsored by Interphaze.

Rules Agreement

I promise to obey all Minnesota laws, Boy Scout of America rules, and all Interphaze rules, including the Interphaze Code of Conduct.

Media Consent

I understand that Interphaze, from time to time, and for several purposes, including publicity, records and documents its games and other activities via photography, video and audio recordings, artwork and other means. In return for being permitted to participate in this Interphaze sponsored event, I hereby authorize Interphaze to utilize any such photographs, recordings, documents, artworks, or other records of my participation in this game or other activity, in any manner it chooses, and without further compensation to me.

Billing Address

First Name

Last Name

Address 1

Address 2

City

State

Postal Code

Country

Phone

I agree to the Terms of Service

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