After School Program Enrollment After School Program Registration Form 2021 Please fill out this registration form to enroll in KidSportzUSA After-School Program. Child's Name* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Gender* Male Female Birthday* MM slash DD slash YYYY Grade* Phone*Parents Name* First Last Email* EMERGENCY INFORMATION:Name*EMERGENCY CONTACT 1 Phone*NameEMERGENCY CONTACT 2 - optional PhoneCHILD RELEASE AUTHORIZATION:Name & Relationship* Phone*Name & Relationship* Phone*Name & Relationship* Phone*DOES YOUR CHILD HAVE ANY ALLERGIES?Hay Fever* Yes No Poison Oak/Ivy* Yes No Bee Sting* Yes No Penicillin* Yes No Food Allergies* Yes No If "YES" please list food allergies I authorize KidSportz USA staff to apply sunscreen to my child's exposed skin.* Yes Initial below if you agree with terms of agreement*I am over the age of 18 and wish to enroll my child in Kidsportz USA. I agree that Kidsportz USA is not responsible for any accidents that happen to my child while in the Kidsportz USA program. I understand that the Kidsportz USA training programs are not medically supervised programs and that these programs were developed for healthy people with no medical conditions or risks (physical or psychological). If my child has an existing medical condition, I will present my coach with a physicians release form, signed and dated by their personal physician. This form represents my physicians approval to participate in the Kidsportz USA training program. I understand that this form must be submitted before you can officially enroll your child. I grant permission to my coach to contact my physician or healthcare professional if I require medical supervision during my childs participation in the training program. No refunds. *Parents must pick up child(ren) no later than 5 minutes after class. PLEASE SELECT WHICH AFTER-SCHOOL PROGRAM YOU WOULD LIKE TO ENROLL IN:Choose one option below:* 2 Day After-School Program = $299 monthly 3 Day After-School Program = $399 monthly 3 Day After-School Program = $499 monthly 5 Day After-School Program = $599 monthly Which days do you need to enroll for?*Please choose the days based on the monthly option you chose above. Mondays Tuesdays Wednesdays Thursdays Fridays CLICK BELOW TO COMPLETE REGISTRATION. You will be taken to Paypal to complete the purchase. * PLEASE NOTE: There is a setup fee of $49 that will be added to the total. CommentsThis field is for validation purposes and should be left unchanged.
