Super Kickers sports corp Online Registration

Registration

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A credit card / checking account is required for registration. Credit card will be saved and charged if payment is not received by a week before class. When signing up for Summer camp you will only have space for 5 class selections. If you are signing up for 6 weeks or more you can do it by e-mail or in person at the PS69 . The 5% discount will be applied to those who register for 6-8 weeks of camp full Time. Payment for the First week tuition required at registration. This is non-refundable

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Home or Primary Phone*

Additional Info

Emergency Contact Info

Voucher number

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Work #

Cell # Receive Text Message Notifications

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Contact #2 First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell # Receive Text Message Notifications

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

School

Grade Level

Allergies

Summer camp registration?

Do you need Bus pick up?

Where is my pick up

First day of Camp

Select days of the week.

Enroll in Classes

Select Another Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

School

Grade Level

Allergies

Summer camp registration?

Do you need Bus pick up?

Where is my pick up

First day of Camp

Select days of the week.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

School

Grade Level

Allergies

Summer camp registration?

Do you need Bus pick up?

Where is my pick up

First day of Camp

Select days of the week.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

School

Grade Level

Allergies

Summer camp registration?

Do you need Bus pick up?

Where is my pick up

First day of Camp

Select days of the week.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

School

Grade Level

Allergies

Summer camp registration?

Do you need Bus pick up?

Where is my pick up

First day of Camp

Select days of the week.

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Assumption of Risk & Release of Liability

I am the parent or legal guardian of and I declare that my child is in good health and free of any
medical problems that would affect his or her ability to participate in the Super Kickers' soccer program, summer camp, or mini camp, or other
sports activity.
I will ensure that my child wears shorts or sweatpants and soccer shoes or sneakers to class and brings a bottle of
water to each class. If my child wears corrective eyeglasses, I will ensure that he or she wears shatterproof
eyeglasses during class.
I understand and agree that I am responsible for the supervision of my child before, during and after classes, and
that I may designate coaches to take my child to the bathroom or change his or her diaper during class, if
necessary.

I acknowledge that playing soccer and sports and participating in a soccer instruction, like all sports activities and instruction,
involves the risk of personal injury. On behalf of the parents, guardians and/or heirs of my child and my child
("we"), I hereby release, discharge and covenant not to sue Super Kickers Sport, Corp., its officers, directors,
coaches, managers, employees, volunteers, representatives, successors and assigns (each a "Release") from any
and all liability, loss, claims, demands, costs or expenses of any kind, under any state or federal law or legal theory,
including without limitation, negligence and personal injury, arising out of my child's participation in the Super
Kicker's program.
We agree not to bring or be part of any legal action or claim against the "Releases", and will indemnify and hold
each "Release" harmless from and against any claims, liability, fees, loss, damages, attorney fees or other legal
expenses arising in connection with such legal action or claim.