MJX MENTAL FITNESS LLC REGISTRATIONS

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JANUARY/FEBRUARY WINTER 2 Indoor WEDNESDAYS MJX Boys and Girls Little Tots Soccer Jann 22, 29, Feb 5, 12, 19, (5-WEEKS) Product Image

JANUARY/FEBRUARY WINTER 2 Indoor WEDNESDAYS MJX Boys and Girls Little Tots Soccer Jann 22, 29, Feb 5, 12, 19, (5-WEEKS) Jan 22, 29, Feb 5, 12, 19 (5-WEEKS) Boys and Girls Ages 3-6 5:00PM-5:55PM Kids Choice Sports Centers

$125.00 Quantity

Volunteer Please Email MJXgirls4ever@gmail.com in order to confirm your mentorship, volunteer schedules, and placement.

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Athlete Information

Athlete's Name*

First NameLast Name

Birth Date*

MonthDayYear

AGE*

Gender*

MaleFemale

For multiple participants: Please Type All Participants Here, Athletes Name, Age, Birthday Day, Gender, T-Shirt Size, Any Health Concerns. (Ex. John Doe, 4, 1/1/2020, Male, Youth Small, Health Concerns N/A)

PLEASE TYPE ALL PARTICIPANTS NAMES IN THIS BOX ABOVE

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Name*

First NameLast Name

Cell Number*

E-mail*

example@example.com

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Does the athlete have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the athlete prescribed an inhaler? If yes, please explain any instructions.

Travel Soccer Club (For Competitive Soccer Training Only)

Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by MJX Mental Fitness LLC ever during the selected camp. In exchange for the acceptance of said child’s candidacy by MJX Mental Fitness LCC ., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless MJX Mental Fitness LCC. and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against MJX Mental Fitness LCC. including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. Programs are non-refundable. Contact us for additional refund or transfer policies. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to the MJX Empowering Girls 4ever . and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation BY ACKNOWLEDGING AND SIGNING (Submitting form) 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.

T Shirt Size

T Shirt Size (If Signing Up Multiple Participants)

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