CKP Pass It Forward - November Registration Form

Pass It Forward: Basketball + Life Skills Clinic

Please fill out the registration information below. If you have any questions please email Chelsea Poppens at ckpathletics@gmail.com . Registration has been extended to Nov. 21st.
Athlete Information
Athlete Full Name*

First NameLast Name
Grade*
School District*
T-Shirt Size*
Which ISU WBB game in December would you be most likely to attend if your athlete got ONE complimentary ticket?
Parent / Guardian Information
Parent Name*

First NameLast Name
E-mail*
example@example.com
Cell Number*
Please enter a valid phone number.
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Information
Emergency Contact Name*

First NameLast Name
Relationship to Athlete*
Phone Number*
Please enter a valid phone number.
Does the athlete have any allergies, chronic illness, or medical condition? If yes, please describe. *
Waiver of Release & Liability

By checking this box and signing below, I acknowledge that participation in the CKP Athletics Clinics involves physical activity and inherent risks of injury. I voluntarily assume all risks on behalf of myself/my child.

I hereby release and hold harmless CKP Foundation, CKP Athletics LLC, Shoot360, its sponsors, coaches, volunteers, and staff from any liability for injury, illness, or damages arising from participation.

I also authorize emergency medical care if necessary and acknowledge that I/my child are responsible for any related expenses. I grant permission for photos/videos of me/my child to be used for promotional purposes.
I have read and fully understand the Waiver & Release of Liability above, and I agree to its terms on behalf of myself/my child.
Signature*

Clear
Date*

MonthDayYear
Date
Clinic Selection
Please Note:
** Lunch is Provided: A meal will be included for all participants. If your child has food allergies or prefers specific foods, please send a packed lunch with them on the day of camp. **
Which Session Are you Registering For?*

Friday, Nov. 28th: 10am-2pm (6th-8th Graders)Saturday, Nov. 29th: 10am-2pm (4th & 5th Graders)Sunday, Nov. 30th: 10am-2pm (High Schoolers)
I would like to apply for a scholarship (Limited availability)

Yes
Scholarship Application
Note: These questions help us ensure scholarships are awarded to families who need them most. Your responses are kept private and used only for scholarship selection. If selected, you’ll receive a confirmation email with next steps. Limited spots available.
Why would this scholarship be helpful for your family at this time?
Do you currently participate in free/reduced lunch at school?

YesNo
Would your athlete be able to attend the clinic without scholarship support?

YesNo
How many children or dependents are currently living in your household?
Please select your estimated annual household income (optional)

Under $25,000$25,000–$49,999$50,000–$74,999$75,000–$99,999$100,000+Prefer not to answer
Anything else you’d like us to know?
Payments
Registration has been extended to Friday, Nov. 21st. Use code BLACK FRIDAY for a discount on the registration fee!

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Pass It Forward: Basketball + Life Skills Clinic

Athlete Information

Parent / Guardian Information

Emergency Information

Clinic Selection

Scholarship Application

Payments