Jump Stars Registration Form

Registration Form

Fill out the form carefully for registration
Student Name

First NameMiddle NameLast Name
Grade and Teacher
Gender
Birth Date

MonthDayYear
Parent/Guardian Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number
Phone Number
Emergency Name and Contact Number

AFTERSCHOOL JUMPROPE CLASS WAIVER AND RELEASE OF LIABILITY
Participant Information:
Name:   First Name   Last Name
Date of Birth:   Date
Address:   Street Address   Address Line 2   City   State   Zip
Emergency Contact Information:
Name:   First Name   Last Name
Phone Number:   Area Code   Phone Number
Acknowledgment of Risks:
I, the undersigned, acknowledge that participating in the afterschool jump rope class (the "Activity") involves certain inherent risks. These risks include, but are not limited to, physical injury, falls, and collisions. I understand that while every effort will be made to provide a safe environment and instruction, accidents can still occur.
Assumption of Risk:
I voluntarily assume all risks associated with my participation in the Activity. I understand that my participation is entirely voluntary and that I may withdraw from the Activity at any time.
Release of Liability:
In consideration of being permitted to participate in the Activity, I, on behalf of myself, my heirs, executors, administrators, and assigns, hereby release and hold harmless [Organization/Instructor Name], its officers, employees, agents, and volunteers from any and all claims, demands, causes of action, or liabilities arising out of or related to any injury, loss, or damage that may occur as a result of my participation in the Activity.
Medical Authorization:
In the event of an emergency, I authorize the [Organization/Instructor Name] to seek medical treatment for me (or my child) as deemed necessary. I understand that I am responsible for any medical expenses incurred.
Code of Conduct:
I agree to abide by the rules and guidelines set forth by the [Organization/Instructor Name] for the Activity. I understand that failure to follow these rules may result in my removal from the Activity.
Photo/Video Release:
I consent to the use of any photographs or video recordings taken during the Activity for promotional or informational purposes by [Organization/Instructor Name].
Acknowledgment and Agreement:
By signing this waiver, I acknowledge that I have read, understood, and agree to the terms and conditions set forth above. I further acknowledge that I am signing this waiver voluntarily and with full knowledge of its implications.
Participant's Name:   First Name   Last Name
Date:   Date
Parent/Guardian's Signature:   First Name   Last Name
For [Organization/Instructor Name] Use Only:
Date Received: ___________________________
Received By: ___________________________
Should be Empty: