Registration
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Event:
Start Date/Time:
End Date/Time:
Fee per Student:
Room:
*
- denotes required fields
Family Information
First Name:
*
Last Name:
*
Type
*
Doctor/Physician
Father
Grandparent
Guardian
Mother
Other
Parent
Step Father
Step Mother
Home Phone:
Cell #:
Work #:
Email:
*
(Emails are kept confidential)
Address:
*
City:
*
State:
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Zip:
*
Emergency Contact Info
Students entered below will be added to your family's account
Add New Student #1:
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
School:
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Add New Student #2:
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
School:
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Add New Student #3:
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
School:
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Add New Student #4:
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
School:
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Add New Student #5:
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
School:
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Additional Information:
Release of Liability
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In consideration of allowing the previously declared participant(s) to begin activity at S.P.O.R.T., while on the premises and property of said gym, the undersigned, for themselves and/or being the legal and acting guardian of participant, acting for themselves and on behalf of the participant, release and hold harmless S.P.O.R.T. LLC, its owners, officers, employees, and agents of and from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and /or the undersigned, while in or upon the premises upon which S.P.O.R.T. is conducted, or any premises under the control and supervision of S.P.O.R.T., its owners, officers, employees, or agents or in route to or from any of said premises or while at any premise or place when activities sponsored by or participated in by S.P.O.R.T. LLC, its owners, officers, agents, or employees.
I've read the above and agree.
Assumption of Risk
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Assumption of Risk - Participation in physical activities can involve motion, rotation, and height in a unique environment and as such carries with it a certain assumption of risk. The undersigned and the participant (s) choose to voluntarily enter upon said premises under the control of said corporation, knowing their present condition and knowing that said condition may become more hazardous and dangerous during the time the participant or the undersigned is upon said premises. The undersigned and the participant (s) voluntarily assume any and all risks of loss, damage, or injury that may be sustained by the participant (s) and/or the undersigned or any property owner by them while on or upon said premises described above. The corporation may but shall not be obliged to carry insurance on the participant (s), and the existence of insurance shall not change, alter, or increase the liability of the corporation to the participant and the undersigned or affect the terms of the Release. In signing this Release, the undersigned acknowledges:
*a. That he/she has read thoroughly and understands completely, the terms of Registration and Release and signs it voluntarily.
*b. That the undersigned signing either for themselves, or as Legal Guardian is, in fact, the true and legal guardian and has the consent of the participant.
I've read the above and agree.
Marketing Release
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I understand that my child's likeness may be used in S.P.O.R.T. Gym ads, promotional videos, website material, or various other marketing. These images will be used for S.P.O.R.T. purposes only and will not be given or sold to outside companies or individuals.
I've read the above and agree.
Enter your Full Name:
*
Other Questions/Comments:
Credit Card Verification:
Card Number:
*
Visa
Mastercard
Name as it appears on card:
*
Nickname:
Card Expiration Month:
*
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Exp Year:
*
2024
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2054
Address Line 1:
Address Line 2:
City:
State:
AK
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AR
AZ
CA
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DC
DE
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GA
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IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
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OR
PA
RI
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PR
VI
Zip:
*
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