ChiroSport Summer Performance Program

ChiroSport Summer Performance Program

2023
Athlete's Name

First NameLast Name
Parent's Name

First NameLast Name
Athlete's Phone Number
Please enter a valid phone number.
Parent's Phone Number
Please enter a valid phone number.
Athlete's Email
example@example.com
Parent's Email
example@example.com
Gender

MaleFemale
Date of Birth

MonthDayYear
Upcoming Grade (2023-2024)

6th7th8thFreshmanSophomoreJuniorSeniorCollege
Did you participate in this program last summer?

YesNo
Which program are you interested in?

June - JulyJune - August
What sports are you involved in?

SoccerFootballVolleyballCross CountryGolfBasketballWrestlingGymnasticsCheerleadingSoftballTrack and FieldBaseballBowling
What would be your 1st option for time? (Upcoming 6th and 9th Graders will be between 11 AM - 2 PM)

5 AM6 AM7 AM8 AM9 AM10 AM11 AM12 PM1 PM
What would be your 2nd option for time? (Upcoming 6th and 9th Graders will be between 11 AM - 2 PM)

5 AM6 AM7 AM8 AM9 AM10 AM11 AM12 PM1 PM
If you have any diagnosed health problems, list the condition(s).
If you are on any medications, please list them.
If you have any injuries, please list them.
What additional therapies are being undertaken for the given injury?
T-Shirt Size
1.) Membership Obligation

This agreement is a legally binding obligation for which I am financially responsible. I agree if I fail to pay when a payment is due that I will be required to pay the entire unpaid balance and associated fees immediately. If collection or legal action services are need to collect the unpaid amount, I am responsible for all costs of collections, including attorney's fees of ChiroSport Hartford PC.

2.) Assumption of Risk and Wavier of Liability

I assume all risks of injury and waive all rights to pursue money damages or any
other relief of any kind as a result of anything occurring under the supervision of the ChiroSport coaches or trainers. I acknowledge there is possible danger connected with any physical activity (including the dangers of physical injury and death) and knowingly and voluntarily waive my right to make a legal or
equitable claim of any sort against ChiroSport Hartford PC and all of their owners, employees, agents, successors and assigns from all claims of any sort for damages or for other relief, including but not limited to claims for contribution. This assumption of risk and waiver of liability applies to ourfamily members, successors, heirs, and assigns.

3.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.
I AGREE TO THE ABOVE TERMS & CONDITIONS!

YesNo
Electronic Signature of Parent/Legal Guardian

Clear
Thank you for submitting your form!

You SHOULD be receiving an automated email with detailed information; however, if not, the pricing information is found below. I am unable to attach the Lemke's form on here, but it is attached on the automated email!

We will be in contact with more information as we approach the summer! Attached is the form for enrolling with Lemke's Fitness Training. Please have this filled out and sent to Lemke's before May 5th, 2023.

Payment information:

Due by May 20th!!

Pricing:

June-July Program - $250 ($125/month) ($10/session) plus sign up with Lemke's for 2 months

June-August Program - $350 ($117/month) ($9/session) plus Lemke's for 3 months

Payment Options:

Check - make payable to ChiroSport. Address - 700 N Vandemark Ave Ste 106 Hartford SD 57033

Credit Card - Can be made in clinic or over phone. Phone number - 605-528-3329

Cash - Can be made in clinic.
Should be Empty: