2017 Comet Skippers Jump with the Stars Workshop Registration Form

Participant Information

Partipant Name *

First Name Last Name

School or Team *

Grade *

Birth Date *

Month Day Year

Gender *

Male Female

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Jumper Experience Level *

Basic (Little or no experience) Elementary Intermediate Advanced

T-Shirt Size (1 included with registion, additional can be purchased below) *

Parent/Guardian Information

Name *

First Name Last Name

Home Number *

Area Code Phone Number

Cell Number

Area Code Phone Number

E-mail *

Emergency Information

Emergency Contact's Name *

First Name Last Name

Relationship *

Phone Number *

Area Code Phone Number

Alt. Phone Number

Area Code Phone Number

Payment

Workshop Participant $ 75.00

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

Medical release and Indemnity Agreement

I hereby request that you accept this application for registration in the 2019 Jump with the Stars Workshop of 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 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 possible promotion of the camp.

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: *

2019 Jump With The Stars Registration