|
Register Now! (Click on Blue Area Below)
Fields marked with (*) are required.
Get a $10 discount for referring 5 friends now!
(button to enter 5 names with age and email addresses, then continue to register)
First Name:(*) |
|
Last Name:(*) |
|
Birthday:(*) |
Please use mm/dd/yyyy format and must be aged between 5 to 15 to register.
|
Gender:(*) |
|
Offensive Position:(*) |
|
Defensive Position:(*) |
|
Years Played:(*) |
|
T-Shirt Size:(*)
|
Please select an item |
|
Health Insurance: |
|
Policy Number: |
|
I have had a physical in the past year: |
|
|
|
If "allergy" or "other" is selected above, explain here:(*) |
|
If medication is required, provide details here: |
|
Medication to self-administer: |
|
Parent/Guardian Authorization:(*) |
My child has a physical condition which requires him/her to receive medication as quickly as possible in order to avoid a medical crisis. In the interest of his/her personal well being, I hereby grant my child the authority to carry his/her medication and to self-administer it as directed by the prescribing physician when needed. In granting this permission to self-medicate, I hereby absolve Kids & Pros, Inc. and all of their respective directors, officers, shareholders, subsidiaries partners, agents, sponsors, employees, successors, parents, beneficiaries, heirs executors, administrators, assigns and affiliates thereof (collectively, "Releases"), from any liability or legal responsibility for any condition that may arise from the administration or lack of administration of such medication.
|
| |
|
|
First Name:(*) |
|
Last Name:(*) |
|
Home Phone:(*) |
|
Cell Phone: |
|
Relationship:(*) |
|
Email:(*) |
|
Confirm Email:(*) |
|
Address Line 1:(*) |
|
Address Line 2: |
|
City:(*) |
|
State:(*) |
|
Zip:(*) |
|
|
|
Referred By: |
|
|
|
Purchase Camp Insurance: |
|
Association: |
|
| |
|
| |
|
| (**) Registration has been closed for this event. |
|
