Cra-Z-Dreams Registration Form

Cra-Z-Dreams Jr. Registration Form

(ages 5 to 17)

Cra-Z-Dreams Life Skills Development LLC

Child Information

Name

First NameLast Name

Age

Grade

School Attending

Guardian / Parents Names

First NameLast Name

Address

Street Address

Street Address Line 2

City

Postal / Zip Code

Cell Phone

Area CodePhone Number

Secondary Phone

Area CodePhone Number

E-mail

Pay by Debit or Credit Online My Products (Platinum customers enter # sessions > 10 next to "Quantity")

Platinum Package (10+ sessions)$175.00

Platinum Additional Sessions (# extra sessions above 10)$17.50

Quantity
Item subtotal:

Gold Package (8 sessions)$160.00

Silver Package (6 sessions)$135.00

Bronze Package (4 sessions)$100.00

TW-Group (10+ people) 2-day Workshop + WFLCS + t-shirt$85.00

TW-Group (10+ people) 1-day Workshop + WFLCS$50.00

Cra-Z-Dreams Hosted 2-day Workshop + WFLCS + t-shirt$125.00

Cra-Z-Dreams Hosted 1-day Workshop + WFLCS$75.00

Individual Life Coaching Session (per hour)$100.00

Enter coupon

Subtotal Tax Total $0.00

Desired Package - Pay by Phone (enter # sessions > 10 or discount codes under "Other"). Cra-Z-Dreams will contact you to confirm your order and process payment:

Other

Please choose your child's program(s) below. Scheduling/availability for one-on-one mentorship, basketball or tennis training should be arranged with the program coordinator prior to purchasing. Please do not exceed the number of sessions included in your package.

Please enter any growth areas that should be points of focus for your child along with his/her strengths. If you registered for sports training please include experience, skill level and sports development information. (Send an email to info@cra-z-dreams.com with child's name if you run out of space)

Interested in Volunteering?

One-on-one Mentorship or Sports Training Start Date (Availability TBD)

MonthDayYear

Basketball skill level

	1	2	3	4	5

1 is Beginner, 5 is Advanced

Tennis skill level

	1	2	3	4	5

1 is Beginner, 5 is Advanced

SPORTS REGISTRANTS: My child would like to train or play on the same team with following players. Organizers will attempt to take these requests into consideration along with your skill level when forming teams and/or training groups.

Important Notes

· Dress appropriately (school appropriate attire -- see our guide).

· Keep the classroom/practice area/facility clean.

· Be courteous and respectful to everyone we encounter.

. No food or drinks in classroom/gym, but those might be sold outside of the classroom/gym for participants and others.

· Sports team/training organizers reserve the right to form the teams and/or training groups to ensure maximum benefit and growth of each player/participant.

· Fee: See pricing list/quote (provided separately).

. All members and parents are expected to demonstrate proper respect to teachers, coaches, special guests and other members/students. Cra-Z-Dreams reserves the right to release any member(s) for conduct by him/her or their parent(s) deemed inappropriate or detrimental to the program WITH NO REFUND. We are here to develop character and life skills for each child and maximize the growth of each individual.

Emergency Contact & Health Insurance Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Area CodePhone Number

Does the child you are registering have health insurance?

Insurance Carrier

Name of Policy Holder

Subscriber ID

Group Number

Card Number / Card Date

Does the participating child have any allergies, chronic illness, or medical conditions?

Please describe

Parental Permission For Emergency Treatment

In the event of illness or accident, I give my permission for emergency treatment by qualified medical personnel for my child, and I authorize the person in charge to take my child to:
I give consent for the facility to secure any and all necessary emergency medical care for my child.

Name of Physician / Emergency Medical Care Facility

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Release of Liability

Although the safety of all sport activities is the primary concern, indoor and outdoor sport activities with the VIPERS program may cause injuries and/or death. I expressly assume the risk of injury, death, and/or illness arising from any cause, and agree to waive the right to pursue any claim against Cra-Z-Dreams Life Skills Development LLC and the persons in charge.

I have read and agree to the above conditions

Parent/Guardian's Signature

Relationship to Child

**Pay by Debit or Credit Online** My Products (Platinum customers enter # sessions > 10 next to "Quantity")

Release of Liability

Pay by Debit or Credit Online My Products (Platinum customers enter # sessions > 10 next to "Quantity")