Strength Through Shred Registration Form

Strength Through Shred Registration

Free skateboarding program!
Program Dates
Skater Information
Skater’s Name

First NameLast Name
Birth Date

MonthDayYear
Gender

MaleFemale
Parent/Guardian Information
Name

First NameLast Name
Home Number
Cell Number
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Alt. Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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.
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by A Positive Seed Co. during the selected camp. In exchange for the acceptance of said child’s candidacy by A Positive Seed Co. ., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless A Positive Seed Co. . 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 A Positive Seed Co. . including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. 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.

MEDIA RELEASE:
I grant full permission to use any photographs, videotapes, motion pictures, recordings, or any other record of
myself (or the participant) in this program for promotion of A Positive Seed.
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.
Date

MonthDayYear
Date
Name

First NameLast Name
Should be Empty:

Strength Through Shred Registration

Program Dates

Skater Information