Potomac Shores Kickball League

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Potomac Shores Kickball Team Fee (CAPTAINS REGISTRATION) Product Image

Potomac Shores Kickball Team Fee (CAPTAINS REGISTRATION) Team Fee Covers 10-20 Participants On Roster Captain must register a team and MJX Mental Fitness Will require the captain to send a roster with first and last names. Each player is required to fill out the free jotform waiver including their team name on form in order to be listed on correct roster. Captains will be responsible for collecting player payments and must pay in full the team fee to secure their spot in the league.

$500.00

Potomac Shore Kickball Individual Fee (Free Agent Team Roster Spot) Product Image

Potomac Shore Kickball Individual Fee (Free Agent Team Roster Spot) Once the roster is full the individual registration will close. MJX Director is making 1-3 free agent teams based on availability.

$50.00

Already On A Team (Waiver) Please Enter Team Name Bellow:

$ Free

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Total

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Athlete Information

Athlete's Name*

First NameLast Name

Team Name *

Team Name

T Shirt Size

Birth Date Must Be 18+ To Particpate*

MonthDayYear

Gender*

MaleFemale

Potomac Shores Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-mail*

example@example.com

Cell Number*

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Does the athlete have any allergies, asthma, chronic illness, or medical conditions? If yes, please describe.

Please place me on a team with ____________________________________.

Informed Consent and Acknowledgement I hereby give my approval for my participation in any and all activities prepared by MJX Mental Fitness LLC ever during the selected program. In exchange for the acceptance of my candidacy by MJX Mental Fitness LCC ., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless MJX Mental Fitness LLC. 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 MJX Mental Fitness LCC. including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. Programs are non-refundable. Contact us for additional refund policies differ. There is a risk of being injured that is inherent in all sports activities, Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to the MJX Mental Fitness LLC . and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation BY ACKNOWLEDGING AND SIGNING (Submitting form) 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.

Kickball League

Registration Due May 12th

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