CARE - Superkickers inc Online Registration

Registration

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Sorry, but the class: "Mid Winter Break Mini Camp 02/18/19- 9:00-5:00 5 to 6 years old" is no longer available.

Welcome to Superkickers inc! Please complete the following registration form.

* 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
(Not Contact #1 or #2)*

Do you need a bus pick up?

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*

Disabilites*

Special Needs*

Allergies*

Medications*

I'm allergic to:

After choosing how many days a week you need, please register your child for 2 classes per day you chose according to your child's age group.

Enroll in Classes

Select 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*

Disabilites*

Special Needs*

Allergies*

Medications*

I'm allergic to:

After choosing how many days a week you need, please register your child for 2 classes per day you chose according to your child's age group.

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*

Disabilites*

Special Needs*

Allergies*

Medications*

I'm allergic to:

After choosing how many days a week you need, please register your child for 2 classes per day you chose according to your child's age group.

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*

Disabilites*

Special Needs*

Allergies*

Medications*

I'm allergic to:

After choosing how many days a week you need, please register your child for 2 classes per day you chose according to your child's age group.

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*

Disabilites*

Special Needs*

Allergies*

Medications*

I'm allergic to:

After choosing how many days a week you need, please register your child for 2 classes per day you chose according to your child's age group.

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 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 After School program or mini camp, or any other sports activity. If my child wears corrective eyeglasses, I will ensure that he or she wears shatterproof eyeglasses during class. 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 Inc, 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.