2024 Jump With The Stars Judge Training Registration Form

Name*

First NameLast Name

Jump Rope Team

Team Name If Not Listed Above

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

E-mail*

Please select the workshop you will be attending and indicate if you would like to add a box lunch:

Judge Training - IJRU$25.00

We will offer IJRU judge training for Speed & Freestyle. Please select which judge session(s) you wish to attend in the section below. There will be no refunds after November 25.

Workshop T-Shirt$15.00

If you would like to purchase a workshop shirt (through 11/11/24 only), please check this box and select size.

Size:	Quantity
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult XL
Adult XXL

Subway Lunch$10.00

(Available through 11/28/24 only. Includes 6" sandwich, chips, fruit, cookie and a bottled water)

SandwichCheese

Total $0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

IJRU Judge Training Options (Please indicate what sessions you will take part in.):

Speed (AM)Presentation (PM)Difficulty (PM)Required Elements (PM)

If you have questions or notes for the workshop coordinators, please type them here:

Medical release and Indemnity Agreement

I hereby request that you accept this application for registration in the Comet Skippers Jump with the Stars Workshop of myself (if age 18+) or my child named above, and in consideration of your acceptance of this application, I hereby release Comet Skippers Inc., Mason City Schools, and all of its facilities and employees and all persons associated with the Comet Skippers Jump with the Stars Workshop, of and from all claims or causes of injury to the participant arising from participation in the event, whether such injury is a result of negligence or some other cause. If medical attention is required for injury or illness while at the Comet Skippers Jump with the Stars Workshop, I give permission for such medical care and will be financially responsible. I also give permission for photography and or video to be taken and used in the future for promotional purposes.

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.

I Agree

Signature:*