Beat the Blocks Registration Form

Beat the Blocks Registration Form

Fill in your information below to sign up and learn more about the Beat the Block program!
Your Information
Name

First NameLast Name
Birth date

DayMonthYear
Gender

MaleFemaleOther
Current level

BeginnerIntermediateAdvancedOther
Date

MonthDayYear
Date
Age
Parent/Guardian Information (if child is under 18)
Name

First NameLast Name
Mobile Number

eg 021Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Alternative Emergency Contact
Emergency Contact's Name

First NameLast Name
Mobile Number

eg 021Phone Number
Does the athlete have asthma, allergies, or any other medical condition? If yes, please describe.
Acknowledgement

NOTIFICATION OF RISK

I understand that certain risks and dangers exist in the programs and activities in which the attending adult or minor child voluntarily chooses to participate in at Beat the Blocks. These inherent risks cannot always be foreseen nor eliminated without destroying the unique character of the activities and include, but are not limited to loss or damage to personal property, accidental injury or illness of any kind, or in extreme cases, permanent trauma, disability or death. I understand that Beat the Blocks considers it important for me to know in advance what to expect and to be informed of the inherent risks involved in the outdoor, high adventure types of activities that are listed but not limited to the activities listed in the program catalog. I understand that the above description of the risks is not complete and that there may be other unknown or unanticipated risks. I expressly acknowledge and assume the inherent risks identified herein and those inherent risks not specifically identified. I acknowledge that participating in the activities provided by Beat the Blocks is not compulsory, and hereby knowingly and willingly choose to participate or allow the attending minor child to participate, in spite of and with full knowledge of the risks involved.

INDEMNIFICATION AND HOLD HARMLESS AGREEMENT

Understanding the inherent risks, I individually and as the parent or legal guardian of the attending minor child, AGREE TO RELEASE FROM ANY LIABILITY AND TO DEFEND, INDEMNIFY AND HOLD HARMLESS Beat the Blocks and its officers, directors, employees, servants, volunteers and agents (collectively "Beat the Blocks") from any liability, claims, causes of action, demands, costs, obligations or financial responsibility of every kind and nature, including that resulting from or arising out of NEGLIGENCE of Beat the Blocks, for any incident, injury or accident occurring to myself, the attending minor child, or member of my family, while engaging in or observing any activity at Beat the Blocks.

By agreeing to this indemnification, I am knowingly and willingly choosing to be financially responsible for any future claims brought against Beat the Blocks. I acknowledge that I am voluntarily electing to allow my minor to participate in such activities for their benefit. Knowing of the risks, I hereby EXPRESSLY AGREE to HOLD HARMLESS and INDEMNIFY Beat the Blocks for any claims that may be brought by my minor child or family members.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature

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