Student Registration Form Jakes Place

Homeschool PE Registration
Parent/Guardian Info
Name*

First NameLast Name
e-mail*
Primary Phone*

Area CodePhone Number
Emergency Contact (If Parent/Guardian cannot be reached)*
Relationship to Student*
Emergency Phone*

Area CodePhone Number
Student Info
Student Name*

First NameLast Name
Age*
Add Student 2?

Add Student 2
Student 2 Info
Student Name*

First NameLast Name
Age*
Add Student 3?

Add Student 3
3 Student Info
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Notes:
Terms and Conditions
Today's Date

MonthDayYear
Date
By checking 'I Agree' below and submitting this form, you, the Parent or Guardian of the above student(s), agree to release Jake's Place, including instructors and assistants from liability for any and all injuries which may occur while training, practicing, performing, or during any activity. You also agree that you are responsible for health and accident insurance and any medical costs incurred due to injury. You give permission for emergency medical transportation and treatment of your student(s) at your expense should the need arise. You also give your permission for the public display of any visual images that your child may appear in.
I Agree
The class begins September 25 and runs for 8 weeks, ending November 13.

Payments are split into 4-week sessions, allowing you to commit in shorter increments if needed. Cost is $40 per child, with $30 for each additional sibling. Please let us know if you plan to participate for just 4 weeks, or reach out with any questions. Thank you!
Should be Empty:

Homeschool PE Registration

Parent/Guardian Info

Student Info

Student 2 Info

3 Student Info

Terms and Conditions