Anti-Bullying Workshop / Assemblies RegistrationSports & Fitness Training Registration - (1 Month) Child's Name* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Gender*MaleFemaleBirthday* Date Format: MM slash DD slash YYYY Grade*Parents Name* First Last Phone*Email* EMERGENCY INFORMATION:Name*EMERGENCY CONTACT 1 Phone*Name*EMERGENCY CONTACT 2 Phone*CHILD RELEASE AUTHORIZATION:Name & Relationship*Phone*Name & Relationship*Phone*Name & Relationship*Phone*INFORMATION REQUIRED BY STATE LAW:Health Insurance Company*Policy Number*Family Physician*Phone*DOES YOUR CHILD HAVE ANY ALLERGIES?Please select:* Yes NoHay Fever* Yes NoPoison Oak/Ivy* Yes NoBee Sting* Yes NoPenicillin* Yes NoFood Allergies* Yes NoIf "Yes" Please list food allergies:*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.One-Time Enrollment Fee* Price: $49.00 SPORTS & FITNESS TRAINING FOR 1 MONTHPlease select below:*1 Month of Sports & Fitness Training for $149.00
