Registration Form

Participant

Last name (child)

First name (child)

Date of Birth (YYYY/MM/DD)

Program Location

Program Name

Program Start Date

Child's Interest

Primary Contact Information

Last name

First name

Relationship to Child

Cell

Secondary phone

Emergency Contact Information

Last name

First name

Relationship to Child

Cell

Secondary phone

Medication information

Allergies

Medical Conditions/ Injuries

Injuries

Please read the following agreements carefully.

I, undersigned, agree that I am aware that my child named above will be engaging in physical exercise which may include, but is not limited to, various sports, coordination, games, events, and general fi tness training like running, jumping, skipping, etc. which could cause injury to him/her/they. I understand that my child is voluntarily participating in these activities and is assuming all risks of injury that may result from engaging in any exercise program or sport related event including tripping, slipping, colliding or falling.

Media Consent

This portion is to be completed to allow Get Set Go Athletics to record, film, or photograph children or their work which may be posted on the Get Set Go Athletics website (currently under construction) and on social media sites. We understand and respect everyone’s privacy and will take that into consideration when/if documenting daily program activities.

Please mark this box if you AGREE to have your child and their work recorded, filmed or photographed during program hours. Please mark this box if you DO NOT AGREE to have your child and their work recorded, filmed or photographed during program hours.

Please read the following agreements carefully.

I have read and completed this registration form in full and agree to abide by each statement outlined above.

Parent/Guardian Signature

Date

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